Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, overbite, Class I malocclusion, normal vertical growth pattern, maxillary and mandibular crowding, incisor protrusion and buccal crossbite

Treatment: Braces and Monthly Visits

The insurer denied coverage for braces and monthly visits.

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, copies of peer reviewed literature 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, Class I malocclusion, normal vertical growth pattern, maxillary and mandibular crowding, incisor protrusion and buccal crossbite and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index, attaining 21 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 a score of 8 points by internal reviewers on the HLD index. The orthodontist is appealing the decision.

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, 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 does not claim an automatic qualifying condition and completes the second section of the index, arriving at 21 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist, attaining a total of 21 points on the HLD index (3 overjet, 3 over bite, 3 ectopic eruption, 10 anterior crowding, 2 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 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.

In this case, the patient's own Orthodontist-completed HLD index total score of 21 points remains below the threshold of 26 points to justify orthodontic care. The coverage for braces and monthly visits is not considered medically necessary for this patient. 

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

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