Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class II Malocclusion, Maxillary and Mandibular Crowding, Deep Impinging Overbite and Posterior Crossbite

Treatment: D8080- Comprehensive Orthodontic Treatment

The insurer denied the D8080- Comprehensive Orthodontic Treatment.

The denial was overturned.

This is a patient presented for evaluation for orthodontic care. The orthodontists recommended comprehensive orthodontics due to skeletal Class II malocclusion, maxillary and mandibular crowding, deep impinging overbite and posterior crossbite among other findings. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required medical necessity requirements nor is there evidence of significant skeletofacial deformities. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the standard in New York State requires, as of September I, 2012, the use of an Orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report 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, although not included in the submitted documentation, the treating orthodontist identifies, and clinical documentation corroborates, what would represent an automatic qualifying condition of deep impinging overbite with severe soft tissue damage which supports the medical necessity of comprehensive orthodontic care. In this case, the clinical circumstance does meet medical necessity criteria to justify orthodontic care.

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 including:
 
Beglin, et al. A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need. Am J Orthod Dentofacial Orthoped 2001, 120: 240-6,

Parker. A study of 1000 malocclusions selected by the HLD Index. Am J Orthod
Dentofacial Orthoped 1999; 115:343-51,

Theis, eta. Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index. Am J Orthod Dentofacial Orthoped 2005,
128:708-15.

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.

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient. 

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

Based on the above, the medical necessity for D8080- Comprehensive Orthodontic Treatment is substantiated.  The insurer's denial is overturned