What does “medical necessity” mean?

Q:  When I tried to use our new orthodontic benefit for my daughter, the orthodontist said she wouldn’t get approved for coverage because her case wasn’t “medically necessary.”  Her teeth look very crooked to me.  Can you discuss?


A:  As parents, we want our children to have nice straight teeth.  We know there are social benefits for people with attractive smiles such as better jobs, enhanced dating opportunities, and higher self-esteem.  We also know there are minor health benefits when teeth are aligned such as easier cleaning so fewer cavities or gum problems.
medical necessityBut orthodontics is generally regarded as an elective choice.  If your daughter’s teeth are not straight,


the sky won’t fall down.  She’ll continue to be able to chew and receive nutrition.  With diligent brushing and flossing, she can keep things healthy.  And her crooked teeth and prominent canines will just be something that her loved ones notice for a while and then ignore – like the cowlick in her hair and the way she sneezes in threes.


Or not.  As orthodontists, we firmly believe that having straight teeth provides distinct health and social benefits.  But strictly speaking, as long as you can speak and chew, your teeth and jaws are functioning adequately.
CleftSadly, there are some individuals who cannot chew.  Their jaws are malformed and the top teeth don’t touch the bottom teeth.  Or they were born with a cleft palate, which means the split in their upper jaw bone might result in teeth growing sideways or completely out of position.  There are actually many developmental anomalies that require medical intervention.  After the oral surgeries to reposition the dental bones, skilled orthodontists finish the cases by focusing on functional alignments. Insurance for “medically necessary” purposes is intended for these patients.


And thank goodness, right?  In earlier days, these serious situations might have gone unattended and these people were condemned to a lifetime of unimaginable difficulties.


It might be important to know that rarely do our patients have insurance that fully covers their orthodontic care.  Some may have a $1000 lifetime limit, which is like having a 15–20 % coupon.  According to the American Association of Orthodontics, 85% of the cases submitted for policies with a medical necessity clause are rejected.  Dr. Foley is very familiar with the list of requirements and therefore knows which cases will be turned down and which ones might have a shot.  He can give you some guidance so you don’t lose months while waiting for the insurance company’s response.


In conclusion, you are not alone in your disappointment.  Since the advent of the Affordable Care Act, many people who had never had dental insurance before thought they suddenly had orthodontic coverage on their new medical/dental plans.  But the “medically necessary” requirement covers only a very small percentage of patients.



The majority of our patients realize that orthodontics is an important investment, so they work with our Treatment Coordinator to set up manageable monthly payments.  And when they see their new smiles, they are so glad they did!