Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Codes D8070 comprehensive orthodontic treatment of the transitional dentition, D8670 periodic orthodontic treatment visit (x 12) and D8680 orthodontic retention (removal of appliances). 

The insurer denied coverage for codes D8070 comprehensive orthodontic treatment of the transitional dentition, D8670 periodic orthodontic treatment visit (x 12) and D8680 orthodontic retention (removal of appliances). 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, and anterior crowding in addition to TMJ (temporomandibular joint) tenderness and range of motion issues. The orthodontist has completed the HLD (Handicapping Labio- Lingual Deviation) index) attaining 26 total points. 

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 the use of an orthodontic Index, the Handicapping Labio- Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual 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 completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which meets the threshold of 26 points to support 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. 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. 

Codes D8070 comprehensive orthodontic treatment of the transitional dentition and D8670 periodic orthodontic treatment visit (x 12) and D8680 orthodontic retention (removal of appliances) is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for codes D8070 comprehensive orthodontic treatment of the transitional dentition, D8670 periodic orthodontic treatment visit (x 12) and D8680 orthodontic retention (removal of appliances) is overturned. Medical Necessity is substantiated.