Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Orthodontic braces (code D8080). 

The insurer denied coverage for orthodontic braces (code D8080). 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, comprehensive pediatric dentistry and orthodontist treatment records, as well as insurance correspondence, it appears that this patient presented for evaluation for dental care as well as orthodontic care. The orthodontist identified several clinical findings including Class III, mandibular protrusion, ectopic eruption, anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labia-Lingual Deviation Index Report (HLD) index attaining 32 total points to support orthodontic care. 

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 Labia-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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 32 points to justify orthodontic care. However, the HLD form from the orthodontist is incorrectly completed.  The instructions clearly state "If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions.'' However, both conditions were scored.  As the orthodontist ascribes a higher point total anterior crowding at 10 points, over 6 points for ectopic eruption this is presumed to be the more significant score and removing 6 points for anterior crowding would place the patients HLD score at 26 points. Despite this reduction in point total, by removing the redundant ectopic eruption points, 26 points as required for approval of orthodontic care is attained. Therefore, the patient still meets the HLD requirement of  26 points for approval of 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.  This is confirmed by several studies referenced below. 

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. 

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

The insurer's denial of coverage for the orthodontic braces (code D8080) is overturned. Medical Necessity is substantiated.