Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment dental services for code D8080 braces and code D8670 for monthly visits

The insurer denied coverage for dental services for code D8080 braces and code D8670 for monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, ectopic eruption. and anterior crowding and has recommended orthodontics. The orthodontist has completed the HLD (handicapping labio-lingual deviation) index attaining 26 total points to support orthodontic care. 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 12 points. The patient's mother is appealing the decision.

Upon review of the submitted documentation 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, an 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.  In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.

However, the orthodontist's HLD form 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." the orthodontist however did score both conditions. As she ascribes a higher point total to anterior crowding at 10 points over 3 points for ectopic eruption of tooth #31, this is presumed to be the more significant score and removing 3 points for ectopic eruption would place the patients HLD score at 23 points which is below the 26 points required for approval of orthodontic care. Therefore, whether the HLD index of the insurer or orthodontist is accepted, both are below 26 points and therefore neither meet 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.

Each of the 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 clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The insurer's denial of coverage for the dental services for code D8080 braces and code D8670 for monthly visits is upheld. Medical Necessity is not substantiated