Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite

Treatment: Comprehensive orthodontic treatment

The insurer denied coverage for comprehensive orthodontic treatment. 
 
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 anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index as required and has chosen the automatically qualifying condition of cross bite of individual anterior teeth (mandibular lateral incisors) 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 5 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, New York State requires, as of September 1, 2012, the use of an orthodontic index, the 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 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 score on the HLD index attains 5 points (2 overjet, 1 overbite, 2 labiolingual spread), which is below the required 26 points. 

Regarding the validity of the HLD 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 the denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The comprehensive orthodontic treatment of the adolescent dentition and periodic orthodontic treatment visit is not considered medically necessary for this patient.

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