Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II malocclusion

Treatment: Comprehensive orthodontics

The insurer is denied coverage for comprehensive orthodontic treatment (code D8080) and periodic orthodontic treatment visits (code D8670) as not medically necessary.

The denial is upheld.

This male patient has a history of a skeletal class II retruded mandible, normal vertical growth pattern, permanent dentition, moderate maxillary spacing, moderate mandibular spacing, an open bite and a severely excessive overjet.  The treatment sequence would include comprehensive orthodontics, full maxillary and then mandibular braces, high-pull headgear, possible interproximal reduction and a retention for at least 3 months full time.  The patient understands that the malocclusion has a high tendency to relapse.  The jaw growth is unpredictable, and the patient may need surgical correction by an oral surgeon at skeletal maturity (approximately 18 years of age).  Although the handicapping labio-lingual deviation (HLD) index score was less than 26, the patient has a handicapping malocclusion. Failure to receive orthodontic treatment will result in the need for orthognathic surgery later. The estimated treatment time is from 24 to 30 months.

The orthodontist identified several clinical findings including overjet, Class II malocclusion, retruded mandible, normal vertical growth pattern, open bite, maxillary and mandibular spacing and excessive overjet and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 15 total points to support orthodontic care. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 15 points to justify orthodontic care. The index completed by the orthodontist attaining a total of 15 points on the HLD index (7 overjet, 8 open bite,) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for comprehensive orthodontic treatment (code D8080) and periodic orthodontic treatment visits (code D8670) is upheld.  The medical necessity is not substantiated.