Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skeletal Class I, Maxillary and Mandibular Crowding and Impacted Canines.
Treatment:  Braces (comprehensive orthodontic treatment).

The insurer denied braces (comprehensive orthodontic treatment).  The denial was upheld.

This is a patient, who consulted an orthodontist for an evaluation of orthodontic treatment.  A series of diagnostic tests were performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding and impacted canines.  As required, a HLD index was performed.  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 only 13 points on review by internal reviewers.  The patient's mother is appealing on behalf of the patient.

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, 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 claims an automatic qualifying condition of
impacted permanent anteriors where extraction is not indicated.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  This reviewer concurs with the findings of the insurer of attaining 13 points on the HLD index (3 points overjet, 2 points overbite, 5 anterior crowding, 3 points labiolingual spread).
 
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.

Each of the cited 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.

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

Braces (comprehensive orthodontic treatment), adjustment for braces (periodic orthodontic treatment visit) and retainers (orthodontic retention) are not considered medically necessary for this patient.

The carrier's denial of coverage for braces (comprehensive orthodontic treatment), adjustment for braces (periodic orthodontic treatment visit), and retainers (orthodontic retention) is upheld.  The medical necessity is not substantiated.