Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces (comprehensive orthodontic treatment of adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 
The insurer denied coverage braces (comprehensive orthodontic treatment of adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 
The denial is overturned. 
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, and anterior crowding.  The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 27 total points. 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 attaining only 11 points on the HLD index by internal reviewers. The dentist's office is appealing the decision 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 significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, 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 the second portion of the index arriving at 27 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist which exceeds the threshold of 26 points to support 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. 

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval. 

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

Braces (comprehensive orthodontic treatment of adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is considered medically necessary for this patient. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The medical necessity for braces (comprehensive orthodontic treatment of adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is substantiated.