Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Malocclusion.
Treatment:  Adjustment of Braces (Periodic Orthodontic Treatment Visit) and Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition).

The insurer denied coverage for adjustment of braces (periodic orthodontic treatment visit) and insertion of 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, and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings, including anterior crossbite, among other findings, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Index (HLD) index, choosing the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

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 the 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. As no gingival recession or clinical attachment loss is identified in the area noted by the orthodontist, it does not fulfill the correct criteria for approval using this automatically qualifying condition. As it does not meet the stipulated criteria for approval of orthodontic care, comprehensive orthodontic treatment is considered not medically necessary.

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 adjustment of braces (periodic orthodontic treatment visit) and insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) services is not substantiated.