Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces

The insurer has denied coverage for the adjustment of braces (periodic orthodontic treatment visit) and the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition). 
The denial is upheld. 

This is a male patient who was evaluated for orthodontic treatment. The Handicapping Labio-Lingual Deviation (HLD) Index report by the treating Doctor of Dental Surgery (DDS) indicates a total score of 10. A report from Braces World Orthodontics listed the following diagnoses: Class I molar, Class I canine, moderate crowding upper and lower, overjet: 3mm, overbite: 2mm. Authorization is being requested for the adjustment of braces (periodic orthodontic treatment visit) and the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition).

The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 18 total points to support orthodontic care. 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 having attained scores of 9 and 10 points on the HLD index. 

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, 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 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 18 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 9 points on the HLD index (2 points overjet, 1 point overbite, 5 points anterior crowding, 1 point labiolingual spread), which is below the threshold of 26 points to support orthodontic care. Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
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.

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

The carrier's denial of coverage for the adjustment of braces (periodic orthodontic treatment visit) and the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) is upheld. The medical necessity is not substantiated.