Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excessive Overjet and Speech Difficulties

Treatment braces (D8080)

The insurer denied coverage for braces (D8080).

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 excessive overjet and speech difficulties. The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm 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 the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 17 points on review by internal reviewers.

Although 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 the use of an orthodontic index, the HLD. 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 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care as there is no objective documentation of speech difficulties. This reviewer concurs with the HLD index of the insurer attaining 17 points (9 points overjet, 5 points overbite, 3 points labiolingual spread).

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 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. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

There was sufficient evidence to support that braces were not considered medically necessary treatment for the patient's condition.

The healthcare plan did act reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for braces (D8080) is upheld. Medical necessity is not substantiated.