Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary crowding.

Treatment: D8080 comprehensive orthodontic treatment of the adolescent dentition (braces), D8670 periodic orthodontic monthly treatment visits x 12.

The insurer denied coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition (braces), D8670 periodic orthodontic monthly treatment visits x 12.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometer radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, deep bite, excessive overjet, and anterior crossbite with gingival attachment loss (mandibular right canine) in addition to other clinical findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

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, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation index report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 claims an automatic qualifying condition of 
cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Deviation index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 

Each of these 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. Recommendation: overturn denial as the clinical circumstance as presented does 
substantiate medical/dental necessity of orthodontic care.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the D8080 comprehensive orthodontic treatment of the adolescent dentition (braces), D8670 periodic orthodontic monthly treatment visits x 12 is overturned. Medical necessity is substantiated.