Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, and deep impinging overbite

Treatment D8080 braces; D8670 monthly visit x (times)12; D8680 retainer; D8681 removable orthodontic retainer adjustment

The insurer denied coverage for D8080 braces; D8670 monthly visit x12; D8680 retainer; D8681 removable orthodontic retainer adjustment

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 9 points on review by internal reviewers. The patient's mother is appealing.

Upon review of the submitted documentation, 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 quality for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 9 points (4 points overjet, 4 points overbite, and 1 point labiolingual spread).

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.

Each of the 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.

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces; D8670 monthly visit x12; D8680 retainer; D8681 removable orthodontic retainer adjustment is upheld. Medical necessity is not substantiated.