Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion.
Treatment: D8080 Braces, D8670 Monthly Visits X 12 and D8680 Retainer.

The insurer denied coverage for D8080 Braces, D8670 monthly visits X 12 and D8680 Retainer.  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, and insurer correspondence, this patient was presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics, due to anterior crossbite with gingival attachment loss, among other clinical findings. 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 # (number) 22, 27 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 circumstances do not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining 9 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 the 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 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 
cross bite 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 circumstances do not 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 this methodology for assessing orthodontic needs is valid. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, it has been determined to represent an appropriate approach for assessing orthodontic needs. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

The medical necessity for D8080 Braces, D8670 Monthly Visits X 12, and D8680 Retainer is not substantiated.