Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding
Treatment is for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment)
The insurer denied coverage for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment)
The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to retruded mandible, maxillary and mandibular crowding, open bite, excessive overjet and impacted permanent maxillary right canine. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 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 only 8 points on review by 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 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 claims an automatic qualifying condition of impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care as the canines appear to be emptying. This reviewer concurs with the findings of the insurer of attaining 8 points on the HLD index (4 points overjet, 2 points overbite, 2 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. 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. 

Uphold the denial 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 braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment) is upheld. Medical Necessity is not substantiated.