Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (Class I malocclusion, upper and lower arch crowding, anterior crossbite with gingival attachment loss, and maxillary and mandibular incisor protrusion). 

Treatment: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and the adjustment of braces (periodic orthodontic treatment visit). 

The insurer denied coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and the adjustment of braces (periodic orthodontic treatment visit). 

The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to Class I malocclusion, upper and lower arch crowding, anterior crossbite with gingival attachment loss, and maxillary and mandibular incisor protrusion. 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 gingival recession are present. 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 11 and 16 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 significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an 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 and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the insurer attaining a score of 16 points on the HLD index (2 overjet, 2 overbite, 10 anterior crowding, 2 labiolingual spread) which is below the threshold of 26 points 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.

Each of the 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 in the best interest of the patient.

The coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and the adjustment of braces (periodic orthodontic treatment visit) is not considered medically necessary for this patient. The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. 

The insurer's denial of coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and the adjustment of braces (periodic orthodontic treatment visit) is upheld. Medical necessity is not substantiated.