Many patients with crooked teeth lack dental plans with orthodontia coverage. However, most have health insurance through private companies or Medicaid.
Figuring out how to get braces covered by medical insurance can make orthodontic treatment more affordable.
You must show a medically necessary reason. This reason is more challenging for adults to prove than for children.
Ask your orthodontist to send a letter of medical necessity. This letter should request preauthorization before treatment starts. The letter must include diagnostic records and a written narrative supporting the request.
Medical Coverage For Adults
Health insurance may cover orthodontia if the adult meets specific conditions. The definition of medically necessary treatment is stricter for members over 21.
Dental braces must prevent or treat injuries, diseases, or symptoms. Here are examples that likely qualify if your doctor collaborates with your orthodontist when submitting the claim.
Accidental Injury
Medical insurance may cover braces when an adult member suffers an accident, such as a broken jaw. The orthodontia would reposition teeth due to this injury.
Medical insurance may pay for dental work if it is part of another covered service, like treating a broken jaw. Braces may be needed as part of these treatments.
- X-rays to visualize the fracture
- Computed Tomography (CT) Scans to check for other broken bones
- Surgery to insert metal plates to promote healing
- Wiring the jaw closed to restrict movement
Illnesses
Medical insurance may cover dental braces when an adult suffers from sleep apnea or temporal joint disorders (TMJ). Orthodontia would reposition teeth due to one of these illnesses.
Health insurance may cover orthognathic surgery when medically necessary. Patients usually wear braces for 6–18 months before and 3–6 months after the surgery to align teeth.
Braces are essential to jaw surgery for treating sleep apnea or TMJ.
Medical Coverage For Teenagers
Health insurance may cover dental braces for teenagers for additional reasons. The definition of medically necessary treatment expands to include facial birth defects or injuries. Medicaid rules are less restrictive.
Congenital Disorders
Health insurance may cover dental braces for teenagers suffering from congenital abnormalities. These severe facial birth defects or injuries affect speech, swallowing, or chewing.
Medical insurance sometimes pays for pediatric dental work. The correction of many congenital defects fits the medically necessary definition.
- Cleft Lip and or Cleft Palate
- Crouzon Syndrome/Craniofacial Dysostosis
- Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia
- Parry-Romberg Syndrome/Progressive Hemifacial Atrophy
- Pierre-Robin Sequence/Complex
- Treacher-Collins Syndrome/Mandibulofacial Dysostosis
Medicaid Coverage
Medicaid, the government health insurance for low-income families, often pays for braces for teenagers. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit broadens the medically necessary criteria.
Medicaid covers braces for teenagers up to age 21. Most states use a point system to measure the severity of malocclusion. Teen patients must score above a certain threshold to qualify.
Your local orthodontist who accepts Medicaid should know the scoring method in your state and help you gather the needed documents for a claim.
Proving Medical Necessity
Providing strong evidence of medical necessity, as defined in your state, is key to getting your health insurance to cover orthodontic treatment. Shopping around for a different plan is not the solution.
Qualifying Criteria
The definition of medically necessary treatment is different in every state. Learning the rules is crucial for getting your health insurance to cover braces.
The standards will be different for children and adults. Contact your state insurance department for their precise definition.
The American Association of Orthodontists has proposed nationwide standards that you can use as a starting point.
- Overjet equal to or greater than 9mm
- Reverse overjet equal to or greater than 3.5mm
- Posterior crossbite with no functional occlusal contact
- Lateral or anterior open bite equal to or greater than 4mm
- Impinging overbite with either palatal trauma or mandibular anterior gingival trauma
- One or more impacted teeth with an eruption that is impeded (excluding third molars)
- Defects of cleft lip and palate or other craniofacial anomalies or trauma
- Congenitally missing teeth (extensive hypodontia) of at least one tooth per quadrant
Documentation Requirements
Your doctor and orthodontist must work together to write a letter of medical necessity for preauthorization before treatment. Most health insurance plans will require this preliminary step.
The letter of medical necessity should contain these critical elements.
Diagnostic Records
The orthodontist should include recent diagnostic records supporting the preauthorization request.
- Panoramic radiograph or full-mouth series of radiographs
- Cephalometric radiograph
- A digital photographic series of eight images
- Digital or Plaster Models of both arches
Written Narrative
The providers must present a written narrative supporting the preauthorization request, including these elements.
- A diagnostic summary of the patient’s condition
- A description of how the diagnosis relates to the condition
- A statement as to why less costly therapy is not appropriate
- An explanation of how the treatment will eliminate the condition
