Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II molar malocclusion, maxillary crowding, incisor protrusion and excessive overjet and deep bite). 

Treatment: D8080 orthodontic treatment. 

The insurer denied coverage for D8080 orthodontic treatment. 

The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal Class II molar malocclusion, maxillary crowding, incisor protrusion and excessive overjet and deep bite. The Orthodontist has completed the Handicapping labio-lingual (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet and reported  masticatory/speech difficulties, to support orthodontic necessity.  The insurer has denied coverage  for orthodontic treatment as not medically necessary, stating that the clinical  circumstance does not meet the required handicapping malocclusion medical necessity  requirements on the HLD index attaining only 18 points on review by their 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, as of September 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 claims an automatic qualifying condition of overjet
greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. 

This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 18 points (10 points overjet,  5 points overbite, 3 points labiolingual spread).
 
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. 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 act reasonably and with sound medical judgment in the, best interest of the patient. D8080 orthodontic treatment is not considered medically necessary for this patient.

The insurer's denial of coverage for D8080 orthodontic treatment is upheld. Medical Necessity is not substantiated.