Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.  

Treatment: Retainer, braces and monthly visits 

The insurer denied coverage for retainer, braces and monthly visits. 

The denial is upheld.

The patient was a female child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images narrative letter from the patient's mother, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including Class I malocclusion, maxillary crowding, mandibular spacing and has recommended orthodontics.  The orthodontist has completed the HLD index attaining 3 total points to support orthodontic care.  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 having attained a score of II points on the HLD index.  The patient's mother is appealing the decision.

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 Handicapping Labia-Lingual Deviation Index is utilizes.  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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 3 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 11 points on the HLD index (2 points overjet, 2 points overbite, 4 points anterior open bite, 3 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index (and in fact has a lower score total than the insurer) as required for orthodontic approval.
 
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. Each of the cited 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.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  In this case the patient's own orthodontist completed HLD index total score of 3 points remains significantly below the threshold of 26 points to justify orthodontic care.

The retainer braces (D8080) and monthly visits (D8670) are not considered medically necessary for this patient.

The carrier's denial of coverage for the retainer, braces (D8080) and monthly visits (D8670) is upheld.  The medical necessity is not substantiated.