Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 

Treatment: Braces (D8080) and monthly visits (D8670). 

The insurer denied coverage for braces (D8080) and monthly visits (D8670). 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented orthodontic care.  The Orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss in addition to other clinical findings.  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) 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.  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 attaining a score of 13 points on the HLD index where 26 points is required.  The provider is appealing on behalf of the patient. 

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation 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 claims an automatic qualifying condition of crossbite 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 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 cited below. 

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. 

The clinical circumstance as presented substantiate medical/dental necessity of orthodontic care. The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient. Braces (D8080) and monthly visits (D8670) are considered medically necessary for this patient. 

The insurer's denial of coverage for braces (D8080) and monthly visits (D8670) is reversed.  Medical is substantiated.