Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental malocclusion

Treatment: limited orthodontic treatment of the primary dentition

The insurer denied coverage for limited orthodontic treatment of the primary dentition

The denial is overturned

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified impacted maxillary anterior teeth among other findings. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. 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. Moses Lebowitz is appealing the decision on behalf of the patient noting that the orthodontist identifies the patient would benefit from a rapid palatal expander (RPE) to address the patient's constricted maxilla.

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 Handicapping Labia-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 chose the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. This condition is met justifying orthodontic care. The clinical circumstance as documented meets this criterion for approval of 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 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.

Orthodontic treatment of the primary dentition is considered medically necessary for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for limited orthodontic treatment of the primary dentition is substantiated.