Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visit.
The insurer denied coverage for D8080 braces and D8670 monthly visit.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite ectopic eruption, anterior crowding and posterior unilateral crossbite and has recommended orthodontics. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index attaining 27 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, 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 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care.  However, the dentist HLD form is incorrectly completed.  The instructions clearly state "If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions." The orthodontist however did score both conditions.  As he ascribes a higher point total to ectopic eruption at 6 points over anterior crowding at 5 points this is presumed to be the more significant score and removing 5 points for anterior crowding would place the patient's HLD score at 22 points which is below the 26 points required for approval of orthodontic care. Therefore, whether the HLD index of the insure or orthodontist is accepted both are below 26 points and therefore neither meet the HLD requirement of 26 points for approval of 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 referenced below.

Each of these peer reviewed articles concludes that this index is a valid and reliable 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 the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.