Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8070 braces, D8670 monthly visit x 4

The insurer denied coverage for D8070 braces, D8670 monthly visit x 4

The denial is upheld

The insurer has denied coverage for D8070 braces, D8670 monthly visit x 4. In their Final Adverse Determination letter, they write that the service was requested to straighten the patient's teeth. However, the Clinical Criteria for Comprehensive Orthodontics were not met. Additional documentation was received, but it does not support the need for this service.

The orthodontist is appealing. In an appeal letter, they writes that the mandibular right cuspid is impacted. There are also multiple anterior crossbites with recession and loss of attachment of lower anterior teeth. 

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 presumably (as no completed Handicapping Labio-Lingual Deviations (HLD) Index sent from him for review) due to anterior cross bite with gingival attachment loss, among other clinical findings. 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 22 points on review by internal reviewers. 

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, as of September 1, 2012, 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 presumably claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. With this assumption in mind, as the orthodontist did not complete an HLD Index, this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance do not meet insurer and plan criteria to justify orthodontic care. The HLD index score of the insurer attaining 22 points which is below the threshold of 26 points for approval of orthodontic care, which is the criteria for New York State.

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 (1-3). 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. 

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

The medical necessity for D8070 braces, D8670 monthly visit x 4 is not substantiated.