Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite
Treatment: D8080 braces and D8670 monthly visits
The insurer denied coverage for the D8080 braces and D8670 monthly visits.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage 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 14 points on review 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 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and 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. This reviewer concurs with the HLD index with a total of 14 points (3 points overbite, 4 points overbite, 5 points anterior crowding, 2 points labiolingual spread).

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. 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 circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is upheld. Medical necessity is not substantiated.