Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, and anterior crossbite with gingival attachment loss (canines)

Treatment: Braces

The insurer has denied coverage for braces. The denial was reversed.

This patient is a child. Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, peer reviewed literature, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, and anterior crossbite with gingival attachment loss (canines). The orthodontist has completed the Handicapping Labio-Lingual Deviation (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. 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 8 points on review by internal reviewers. 

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, as of September 1, 2012, the use of an orthodontic Index, the HLD Index Report (HLD, New York State Medicaid program) modeled after HLD 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. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.  Regarding the validity of the HLD 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 including:

Beglin, et al. A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need. Am J Orthod Dentofacial Orthoped 2001; 120: 240-6, 

Parker. A study of 1000 malocclusions selected by the HLD Index. Am J Orthod Dentofacial Orthoped 1999; 115:343-51, 

Theis, et al. Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index. Am J Orthod Dentofacial Orthoped 2005; 128:708-15. 
 
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.  

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. The healthcare plan did not act reasonably or with sound medical judgment or the best interest of the patient.

Based on the above, the medical necessity for braces is substantiated.  The insurer's denial is reversed.