Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss

Treatment: D8080 braces and D8670 monthly visits

The insurer denied coverage for D8080 braces and D8670 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, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular right canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity.

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 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the 
gingival margins are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or 
gingival recession and therefore 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. This reviewer score on the HLD index attains 15 points (3 overjet, 5 overbite, 5 anterior crowding, 2 labiolingual spread) which is below the required 26 points. 

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 needs 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.

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

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is upheld. Medical Necessity is not substantiated.