Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces, Monthly visits, and Retainer

The insurer denied coverage for Braces, Monthly visits, and Retainer

The denial is overturned

The medical records indicate the patient is under the care of an orthodontist for the treatment of a dental malocclusion.

The patient suffers from significant crowding, a very narrow maxilla, and many impacted teeth that include their canines and all premolar teeth which are teeth #6, 11, 22 and 27. The patient also suffers from a posterior crossbite, a huge overjet and severe labial positioning of the incisors. 

The patient is noted to have a Handicapping Labio-Lingual Deviations (HLD) score of 13, per a document.

The request for approval of braces, monthly visits, and a retainer is the topic of this review.

This case meets the standard of care for the treatment of orthodontia. The patient has a very severe malocclusion to include hypoplasia transverse maxilla, severe class two (2) malocclusion with large overjet, and numerous impacted teeth that include #6, 11, 22 and 27. The Handicapping Labio-Lingual Deviations (HLD) score of approval is automatic for impacted teeth, that requires retention and includes the canines as well as the premolars.      

The patient has a severe class two (2) malocclusion and deep overbite with a deep overjet, as well. There is also a posterior crossbite most importantly the patient has many impacted teeth. The proper way to treat this condition is with orthodontia. The request for braces, monthly visits and a retainer follows the standard of care, is prescribed by a licensed dentist, is the most conservative treatment, is not for the convenience of the patient or practitioner and is medically necessary for this patient.

"Introduction: State Medicaid agencies rely on treatment need indices to identify patients with orthodontic medical necessity. The Handicapping Labiolingual Deviations (HLD) index is the most common orthodontic index in the United States. States which have adopted the HLD index have modified it without supporting validation studies. The purpose of this study was to validate all state-modified HLD indices currently used in the United States and to investigate the implementation of the Washington state HLD modification, HLD(WA)... Results: There were many qualitative differences among state-modified HLD indices. State-modified HLD indices had a mean between-state agreement of 79.1%, a mean sensitivity of 41.6%, and a mean specificity of 92.9%. The optimal point thresholds were lower than the current point thresholds for all state-modified HLD indices. When the implementation of HLD(WA) was evaluated, we found a mean approval rate of 35.4% and a mean denial rate of 52.4%. While total mean approval and denial rates were not significantly different among clinic types, there were significant differences among clinic types in the number of applications approved and denied according to index guideline versus reviewer override (p<.01). Conclusions: Our results suggest that state-modified HLD indices fail to identify a considerable percentage of handicapping malocclusions. There is also a lack of consensus among state Medicaid programs on what constitutes a handicapping malocclusion. In addition, our study indicates that there are differences in approval and denial rates among clinic types" (Cousin, T. 2020).

"It is important to note that surgical treatment of malocclusion is typically only recommended in severe cases, and other treatment options, such as braces, may be tried first....The traditional way to treat malocclusion is with the use of braces" (Ghodasra R, Brizuela M. 2023). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Braces, Monthly visits, and Retainer is substantiated.