Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 (braces) comprehensive orthodontic treatment of the adolescent dentition. 

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 male patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite and has recommended orthodontics. The orthodontist has completed the handicapping labio-lingual deviations form (HLD) index attaining 8 total points to support orthodontic care. 

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, New York State requires, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD) modeled after Handicapping Labiolingual Deviation Index. 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 8 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of
20 points on the HLD index (5 overjet, 7 overbite, 3 ectopic eruption, 5 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note, in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval. 

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. 

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. 

Uphold denial as 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.  In this case the patient's own orthodontists completed HLD index total score of 8 points remains below the threshold of 26 points to justify orthodontic care. 

Comprehensive orthodontic treatment of adolescent dentition (D8080) braces is not considered medically necessary for this patient. 

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.