Appeal type: Medical necessity
Decision: Upheld

 Diagnosis: Malocclusion

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

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, as well as 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 Labio-Lingual Deviation (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. 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 19 points 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 Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 there is no gingival recession or clinical attachment loss identified in the images, it does not fulfill this automatically qualifying condition criterion for approval. 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 Labio-Lingual 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 denial as the clinical circumstances as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. As in this case the clinical circumstance does not meet the stipulated criteria for approval based on the orthodontist completed HLD index.

D8080 braces is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 Braces is not substantiated.