Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary crowding, mild mandibular crowding, anterior cross-bite.

Treatment: Orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670).

The insurer denied coverage for orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670).

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 skeletal Class I, normal vertical growth pattern, maxillary and mandibular crowding, Class II canines, and anterior crossbite with gingival attachment loss (mandibular left canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. 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 15 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, and HLD index is utilized. 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.

The treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 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 the insurer and the plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 15 points (i.e., 3 overjet, 4 overbite, 5 anterior crowding and 3 labiolingual spread).

The comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670) are not considered medically necessary for this patient.

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

The carrier's denial of coverage for comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670) should be upheld.  The medical necessity is not substantiated.