Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces and D8670 monthly visit x (times) 12
The insurer denied coverage for D8080 Braces and D8670 monthly visit x 12.
The denial is overturned.

The insurer has denied coverage for D8080 Braces and D8670 monthly visit x (times) 12. In their Final Adverse Determination letter, they write that to qualify for braces the patient needs a score of 26 points. The patient received a score of 12 points. Their dentist says the patient does not qualify for braces and they are not medically necessary. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due excessive overjet among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required stating the patient exhibits the automatically qualifying condition of overjet greater than 9-millimeter (mm) with incompetent lips or reverse overjet greater than 3.5 mm (millimeter) with reported masticatory/speech difficulties to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD index attaining a score of 12 points on review by internal reviewers. Nylah Kydd is appealing on behalf of the patient.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant 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 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 overjet greater than 9mm (millimeter) with incompetent lips or reverse overjet greater than 3.5 mm (millimeter) with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care. In this case, the clinical circumstance does 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 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. 

Based on the above, the insurer's denial must be reversed. 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 D8080 Braces and D8670 monthly visit x (times) 12 is substantiated.