Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, overbite, ectopic eruption, anterior crowding and posterior unilateral crossbite

Treatment insertion of braces (comprehensive orthodontic treatment of the adolescent dentition), adjustment of braces (periodic orthodontic treatment visit), and retainer

The insurer denied coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition), adjustment of braces (periodic orthodontic treatment visit), and retainer

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, anterior crowding and posterior unilateral crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 31 total points. 

Review of the submitted documentation (study models were not provided for review) reveals that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index, the HLD Report, modeled after the Handicapping Labiolingual Deviation Index. 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 completes the second portion of the index, arriving at 31 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 31 points on the HLD index (8 overjet, 8 overbite, 6 ectopic eruption, 5 anterior crowding, 4 posterior unilateral crossbite) which is above the threshold of 26 points to support orthodontic care.

Further, although the insurer states that orthodontic care is generally a noncovered service unless the clinical circumstance meets specific criteria, in fact orthodontic care is a covered service as per the NYS (New York State) dental manual as long as the HLD index is complete, and the criteria of this form are met. And in this case, the patient does exhibit significant craniofacial anomalies to justify care as well.

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 including:

Each peer-reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. The clinical circumstance as presented meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

There was sufficient evidence to support that insertion of braces (comprehensive orthodontic treatment of the adolescent dentition), adjustment of braces (periodic orthodontic treatment visit), and retainer was considered medically/dentally necessary for this patient.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition), adjustment of braces (periodic orthodontic treatment visit), and retainer is reversed. Medical necessity is substantiated.