Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit x 12
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12
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 and notes, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite and anterior crowding as well as impacted permanent anterior teeth and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index twice (both undated), attaining 17 total points to support orthodontic care on one index and choosing the impacted permanent anteriors where extraction is not indicated criterion on the other. 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 21 and 22 points by internal reviewers. The patient's mother is appealing the decision.

Upon review of the submitted documentation 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 completes 2 HLD indices, alternatively claiming an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated and a second index in which the second portion of the index is completed arriving at 17 points to justify orthodontic care.

In this case the patient's clinical circumstance does not meet the automatically qualifying condition of impacted permanent anteriors. Therefore, it does not meet medical necessity criteria based on this criterion. This reviewer does concur with the index completed by the orthodontist attaining a total of 17 points on the HLD index (4 overjet, 4 overbite, 5 anterior crowding, 4 labiolingual spread). However, this point tally is below the threshold of 26 points to support orthodontic care. Of note is 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. 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 D8080 braces and D8670 monthly visit x 12 is not substantiated.