Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and mandibular crowding.
Treatment: D8680 (retainer), D8080 (braces), and D8670 (monthly visit).
The insurer denied coverage for D8680 (retainer), D8080 (braces), and D8670 (monthly visit).
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic car. The orthodontist recommended comprehensive orthodontics due to impacted maxillary canines among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of impacted permanent anteriors (left maxillary lateral incisor and canine) 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 16 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 significant 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 card.  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 quality for orthodontic care a total score of 26 points is necessary. In this case, treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that is 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.

D8680 retainer, D8080 braces and D8670 monthly visit is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for D8680 retainer, D8080 braces, and D8670 monthly visit is overturned. Medical Necessity is substantiated.