Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: Braces.

The insurer denied coverage for braces. The denial is upheld. 

This is an adolescent patient under the care of an orthodontist. The patient has a class one malocclusion with crowding of the upper and lower arch. There is a significant overbite and minimal overjet. The clinical summary mentions that the patient's lower teeth are impinging the palatal tissues.

The previous request for braces was denied in a Final Adverse Determination Denial Notice because it did not meet the criteria for medical necessity. The patient did not meet the required Handicapping Labio-Lingual Deviations (HLD) score of 26 for approval but only reached a score of 12.

It appears that the health plan acted reasonably and with sound medical judgment, as the requested service is not medically necessary.      

Braces are not considered medically necessary for this patient. 

The previous appeal was denied as the patient did not meet the required Handicapping Labio-Lingual Deviations (HLD) score of 26 for approval but only reached 12.

In this request, the photo of the maxillary occlusal view has been altered and cannot be correctly read. This affects any outcome that includes lower incisors impinging upper palatal mucosa. However, the HLD otherwise has yet to be met, and this patient's condition doesn't come close to meeting any of the listed criteria (such as the presence of cleft palate, severe traumatic deviations, impacted permanent anteriors where extraction is not indicated, etc.). 

Based on the review of the available documentation, the records do not support an HLD score of 26, or that the request for braces is medically necessary, the request is denied.

"Several studies have investigated the effects of orthodontic treatment on Oral Health related Quality of Life (OHRQoL) between treated patients and untreated control groups. De Oliveira and Sheiham studied the impact of orthodontic treatment on oral health-related quality of life in Brazilian adolescents and found better oral health-related quality of life in adolescents who had completed orthodontic treatment. However, Taylor et al. did not find any significant association between orthodontic treatment of malocclusion and oral health related quality of life despite the improvement in the health, appearance, social well-being and oral function of the patients" (Jamilian, A. et al. 2016).

"It is commonly expected that orthodontic treatments can increase the quality of life in people affected with malocclusion. In this regard, studies have shown that in cases with mild or moderate disorder, orthodontic treatments have had greater effect on the quality of life compared with those for severe ones. Since orthodontic treatment can directly lead to a change in clients' appearance and their facial features, orthodontists are required to recognize the underlying issues of social psychology and the theory of facial attractiveness. Accordingly, Caglayan et al believed that the need for orthodontic treatment had considerably affected the quality of life of school children but reported no impact on their daily living and psychosocial activities. It is also of note that orthodontic treatments have grown exponentially in order to improve the arrangement of the teeth and esthetics as well as facial beauty" (Imani et al. 2018). 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

The medical necessity for braces is not substantiated.