Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Braces and monthly visit
The insurer denied coverage for braces and monthly visit.
The denial is upheld.
 
Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet among other clinical findings. The orthodontist completed the HLD (Handicapping Labiolingual Deviation) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 (nine) millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD (Handicapping Labiolingual Deviation) index attaining only 20 points on the index 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 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 claims an automatic qualifying condition of overjet greater than 9(nine) mm (millimeters) with incompetent lips or reverse overjet greater than 3.5 mm (millimeters) with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan 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. 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. 

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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 braces and monthly visits is not substantiated.