Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding; Crossbite

Treatment: Orthodontic care (D8080 braces and D8670 monthly visit)

The insurer denied coverage for the orthodontic care.

The denial is upheld. 

This is the case of a female patient who was evaluated for orthodontic treatment. A clinical examination and analysis consisting of a dental and jaw evaluation revealed the following findings: skeletal Class I; vertical growth pattern; permanent dentition; Class II canines; mild maxillary crowding; mild mandibular crowding; and anterior crossbite with gingival attachment loss (mandibular left canine). The following automatic qualifier was chosen on the patient's Handicapping Labio-Lingual Deviation (HLD) Index report: crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.

The Orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, anterior crossbite (mandibular canine) with gingival attachment loss. The Orthodontist 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 8 points on review by internal reviewers. 

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 criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 8 points (2 overjet, 2 overbite, 4 labiolingual spread).

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 medical/dental necessity of orthodontic care. 

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 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.