Marc Bernard Ackerman, DMD, MBA

The American Association of Orthodontics Committee on Medically Necessary Orthodontic Care (MNOC) produced this statement in 2015 that is being promoted at the present time:

“Medically necessary orthodontic care is defined as the treatment of a malocclusion (including craniofacial abnormalities/anomalies) that compromise the patient’s physical, emotional or dental health.  This treatment should be based on a comprehensive assessment and diagnosis done by an orthodontist, in consultation with other health care providers when indicated.”

The Committee went on to recommend against the use of qualitative indices of malocclusion in determining treatment eligibility and instead use the following autoqualifiers for MNOC:

Overjet equal to or greater than 9mm

Reverse overjet equal to or greater than 3.5 mm

Posterior crossbite with no functional occlusal contact

Lateral or anterior open bite equal to or greater than 4 mm

Impinging overbite with either palatal trauma or mandibular anterior gingival trauma

One or more impacted teeth with 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 (excluding third molars)

(Records should include a panoramic radiograph, cephalometric radiograph, and intraoral and extraoral photographs.)

Correct me if I’m wrong but it seems to me that this rubric is antithetical to the emotional (psychosocial and social) component of orthodontic need and does not completely jibe with the Committees’ definition of MNOC? 

The crux of the issue is how orthodontists view what they do and why they do it.  Most orthodontists have been indoctrinated early in their professional education believing that they are treating a disease called malocclusion that always requires treatment and if they work hard enough they may just find a cure. Edward Angle’s point of view was that malocclusion is any deviation from ideal. His graduate, Robert H.W. Strang, modified the concept stating that malocclusion is any deviation from normal occlusion. I’ve been told that Strang used to say that all you needed was one crooked tooth to confirm your diagnosis of malocclusion!

Ideal and Normal are orthodontic fiction. These are words that defy description akin to explaining the taste the water. However, they are at the core of the modern orthodontic construct that governs how and why you should do orthodontics. It is this very mindset that precludes many orthodontists from offering consumers (patients in their mind) what they would term substandard treatment or in other words some limited intervention for any other reason than medical health. You can’t get to ideal if you only straighten the front six teeth and ideal keeps non-orthodontists from taking too large a slice of the orthodontic market.

Have you ever wondered about what the implications of the AAO Committee on MNOC recommendations might be? I would argue that by perpetuating the medicalized model of orthodontics, the specialty will give public and private third-party payers a greater justification for rationing orthodontic benefits to their subscribers and in the process, create larger barriers to access to care.  It will also give third-party payers license to require post treatment documentation that will be measured against ideal and potentially determine how the orthodontist is remunerated in the future. “Orthodontic insurance” is a misnomer and from the beginning has been a slippery slope. For years orthodontists encouraged each other not to participate in what used to be called prepaid plans and later to take direct reimbursement.  Today, only a minority of practices operate in the old model.  Orthodontic insurance has become a necessity for orthodontists to make a living and a necessity for the consumer to be able to afford the over-priced fees that most orthodontists charge.  Now I am not arguing that anyone should charge less than the free market will bear.  I am merely saying that if anything changes in the orthodontic insurance industry, it could have a profound effect on price.

With no valid corroboration of medical orthodontics as well as no consensus on what constitutes an orthodontic condition, what determines orthodontic need, what orthodontic treatment is required, and what orthodontic outcome is acceptable it is not inconceivable that there will be shift in thinking, particularly by private insurers on what kind and by whom orthodontics should be rendered. Let’s face it, orthodontics is a commodity and the price of commodities are market-driven.

In sum, I think that the traditional mentality regarding MNOC is a real danger to orthodontics’ bright future.  I would be really careful for what you wish for, especially if those wishes could have unintended consequences.


6 thoughts on “Medically Necessary Orthodontic Treatment: A Serious Handicap to Orthodontics’ Bright Future

  1. Questions for AAO
    1-define “medically necessary “?
    2-why would an 8 mm. OJ not be medically necessary to correct and a 9mm. would be ie. What substantiating data sets were used to come to these conclusion or was “anecdata” the foundation?
    3 -why not base the quantification on “dentally necessary “?
    The AAO has opened a real “Pandoras Box “that would ,for the sake of our profession and patients,be better left closed . Take a look how such characterizations were used to poorly fund tmnt. in the UK ,NHS !

  2. Andrew:
    I couldn’t agree more. What stimulated me to write this blog was that 2 weeks ago I was told by my insurance coordinator that two private insurer plans were now requiring Medicaid handicapping labiolingual index forms in order for their subscribers to get their orthodontic benefits. I have not seen this before but think it will be coming fast and furious in the states.
    The perfect storm is maintaining high fees, selling orthodontic need based on medical necessity, and encouraging insurers public/private to adopt strictly defined guidelines for approving treatment.
    How do you guard your practice against the fallout? Lower fees, make payment plans that are serviceable by the consumer with extended financing, and don’t make insurance an impediment to the consumer’s starting treatment!

  3. I agree with you, Ben. This is a deceptive situation and I believe deserves a closer look by the AAO before they legislate something “for us” that could create long term affects “to us”!

  4. Dr. Marc, although a year after your blog, I still find this information relevant today. While I am excited that dental services are finally being considered on medical plans as an essential pediatric benefit, access to dental care and caries prevention being an obvious essential to overall health, I am also intrigued in seeing that orthodontic benefits were considered at all. Many of these plans are low-cost to the consumer and have a much higher payout rate than what is paid in. Unlike Mass Health, there is a much smaller write off for my practice on these plans,and I still feel I am servicing a portion of the population who might otherwise be unable to afford treatment. In fairness, I think the heart of the “medically necessary orthodontic” plan is in the right place. The idea is to help provide for the “worst of the worst”, and calling it “Medically Necessary” is indeed debatable, but there has to be some line drawn to make it affordable for the insurance providers as well. I do agree that there is also a discrepancy in judgment amongst private insurances who sway denials in their favor, and there can be a lack of transparency in the qualification process, but it is a start to recognize that dental health, orthodontic or otherwise, should always be an essential benefit for everyone.

  5. I have an 11 yr old who has hypotonia. One of the lower middle teeth, does not have an adult tooth. She will clearly need braces to correct the space once this baby tooth falls out. Is this something that will be considered medically necessary? She is well aware of the condition and is very self conscious of this baby tooth as it is noticed in school . She already lost all of her baby teeth.

  6. Probably not. Medically necessary and orthodontics rarely cross paths. That being said several states have scoring sheets to assess the amount of orthodontic problems and will pay for braces for those who pass a scoring threshold.

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