Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, maxillary spacing and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular left canine)).

Treatment: Comprehensive orthodontic treatment (code D8080) and subsequent periodic orthodontic evaluations (code D8670).

The insurer denied coverage for comprehensive orthodontic treatment (code D8080) and subsequent periodic orthodontic evaluations (code D8670).

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, maxillary spacing and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular left canine). The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by their 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, a HLD index is utilized. 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. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not 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.  This is confirmed by several studies.

Peer reviewed articles conclude 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.

The healthcare plan acted reasonably and with sound medical judgement in the best interest of the patient.

The providers request for comprehensive orthodontic treatment (code D8080) and subsequent periodic orthodontic evaluations (code D8670) is not medically necessary.

The medical necessity for comprehensive orthodontic treatment (code D8080) and subsequent periodic orthodontic evaluations (code D8670) is not substantiated.  The insurer's denial is upheld.