Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, and 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 Handicapping Labio-Lingual Deviation (HLD) 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 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 the 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 Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. If the initial qualifying conditions are not met or selected, additional criteria are considered using a point system. 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 the insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, it has been determined to represent an appropriate approach for assessing orthodontic needs. 


Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care.

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

D8080 braces are not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces is not substantiated.