Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class III, hypoplastic maxilla, maxillary spacing and mandibular crowding, deep bite, excessive overjet, congenitally missing premolars and anterior crossbite with gingival attachment loss
Treatment D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit
The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit
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 III, hypoplastic maxilla, maxillary spacing and mandibular crowding, deep bite, excessive overjet, congenitally missing premolars and anterior crossbite with gingival attachment loss. 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 right 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 10 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, 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that 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 insurer and plan.

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 denial should be upheld as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic dare.

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit is upheld. Medical necessity is not substantiated.