NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Dental Review

Provider Name:

Handicapping Labio-Lingual Deviation (HLD) Index Report_NPI: _Recipient Name:_CIN:____ Age:_Instructions: (Assistance from a recorder/hygienist is recommended.)1.
2. Record all measurements in the order given and round off to the nearest millimeter (mm);3.
4. Enter the requested provider and patient information above. Provider must sign and date at thebottom;
5.
assessment;
6. Submit pages 1 and 2 along with a prior approval request and all necessary diagnostic andCondition

HLD Score

The Conditions In This Section Automatically Qualify For Treatment
Cleft palate deformity or cranio-facial anomaly.
Deep impinging overbite with severe soft tissue damage.
Crossbite of individual anterior teeth when clinical attachment loss and recession of thegingival margin are present.
Severe traumatic deviations.
InImpacted permanent anteriors where extraction is not indicated.
Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm
with reported masticatory/speech difficulties.
The Conditions In This Section Must Total 26 Or More To Qualify For Treatment
Overjet equal to or less than 9mm
Overbite in mm
Mandibular protrusion (reverse overjet) in mm equal to or less than 3.5mm

x5=Open bite in mm

x4=
If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score
only the most severe condition. Do not score both conditions.
Ectopic eruption: Count each tooth, excluding 3rd molar.
Anterior crowding: Score one point for MAXILLA, and/or one point for MANDIBLE; two (2)points maximum. Multiply by five (5).
Labio-Lingual spread (in mm)__x3=_x5=_Posterior unilateral crossbite (involving at least one molar): Score 4 if present.

Total Score

DOH-Ortho (4/2022) Page 1 of 4_NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Dental Review

Handicapping Labio-Lingual Deviation (HLD) Index Report

NOTE: IF A PATIENT DOES NOT MEET ONE OF THE AUTOMATIC QUALIFYING CONDITIONS AND DOES NOTSCORE 26 OR ABOVE ON THE HLD INDEX, HE/SHE MAY BE ELIGIBLE FOR SERVICES DEPENDENT UPONPROFESSIONAL ASSESSMENT OF THE DOH IF MEDICAL NECESSITY IS DOCUMENTED. ATTACH MEDICALEVIDENCE AND APPROPRIATE DOCUMENTATION FOR EACH OF THE FOLLOWING EIGHT AREAS ON A
SEPARATE PIECE OF PAPER IN ADDITION TO COMPLETING THE HLD SCORE SHEET ABOVE.
1.
2.
3.
4.
5.

Principal diagnosis and significant associated diagnosis; and,Prognosis; and,Date of onset of the illness or condition and etiology if known; and,Clinical significance or functional impairment caused by the illness or condition; and,Specific services to be rendered by each discipline and anticipated time for achievement of goals;
and,6. Therapeutic goals to be achieved by each discipline and anticipated time for achievement ofgoals; and,7. Extent of previous services that were provided to address the illness/condition and results of theprior care; and,
8. Any other relevant documentation available which may assist the DOH in making a determination.
All requests for authorization must include:
A completed and signed HLD analysis and narrative describing the nature of the severe
physically handicapping malocclusion, along with any documentation relevant to determining
the nature and extent of the handicap; and,A panoramic and/or mounted full mouth series of intra-oral x-rays; and,A cephalometric x-ray with teeth in centric occlusion and cephalometric analysis / tracing; and,Photographs of frontal and profile views; and,Intra-oral photographs depicting right and left occlusal relationships as well as an anterior view;
and,Maxillary and mandibular occlusal photographs; and,Photos of articulated models can be submitted optionally (Do NOT send stone casts).
Subjective statements submitted by the provider or others must be substantiated by objective documentation such as
photographs, radiographs, credible medical documentation, etc. verifying the nature and extent of the severe physicalhandicapping malocclusion. Requests where there is significant disparity between the subjective documentation (e.g.
Handicapping Labio-Lingual Deviation (HLD) Index Report) and objective documentation (e.g. photographs and / or x-rays)
will be returned for clarification without review.
nal instructions and submission requirements.

http://www.emedny.org/ProviderManuals/Dental/index.html
I certify that I am the furnishing provider and that all of the information and documentation submitted is true, accurate andcomplete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject
me to civil or criminal penalty and/or prosecution under applicable federal and state laws.

Date: _DOH-Ortho (4/2022) Page 2 of 4

NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Dental Review

Handicapping Labio-Lingual Deviation (HLD) Index Report

HLD Index Scoring Instructions
The intent of the Handicapping Labio-Lingual Deviation (HLD) Index is to measure the presence or absence and the degreewith a Boley Gauge (or a disposable ruler) scaled in millimeters. Absence of any conditions must be recorded by entering
The following information is provided to help clarify the categories on the HLD Index Report:
Cleft Palate Deformities or Cranio-Facial Anomaly: I
any further if present. This condition is considered to be a handicapping malocclusion. Documentationmust include photographs and a written report from a qualified specialist(s) treating the deformity /anomaly.
Deep Impinging Overbite with Severe Soft Tissue Damage: When the lower incisors are destroying thesoft tissue of the palate. Tissue laceration and/or clinical attachment loss must be present. Indicate an
handicapping malocclusion.
Crossbite of Individual Anterior Teeth: When clinical attachment loss and recession of the gingival
et when destruction of soft tissue is present anddo not score any further. This condition is considered to be a handicapping malocclusion.
Severe Traumatic Deviations: Traumatic deviations include loss of a premaxilla segment by burns or byaccident, the result of osteomyelitis or other gross pathology. Include a written report and photographs.
sheet and do not score any further. This condition is considered to bea handicapping malocclusion.
Impacted Permanent Anterior Teeth: Demonstrate that anterior tooth (teeth) (incisors and / or cuspids)is (are) impacted (soft or hard tissue); exposure and passive eruption is unlikely; extraction would
compromise the integrity of the arch; and, the tooth (teeth) are treatment planned to be exposed ligated/ banded and brought into the normal arch form; and, there is, or will be sufficient arch space forconsidered to be a handicapping malocclusion.
Overjet Greater than 9mm or Mandibular Protrusion (reverse overjet) is Greater than 3.5mm: Overjet
is greater than 9mm with incompetent lips or the reverse overjet (mandibular protrusion) is greater than
do not score any further. This condition is considered to be a handicapping malocclusion. If the reverse
Overjet Equal to or Less than 9mm:
usion andmeasured from the labial portion of the lower incisors to the labial of the upper incisors. The
measurement may apply to a protruding single tooth as well as to the whole arch. Round thismeasurement to the nearest millimeter and enter on the score sheet.
Overbite in Millimeters: A pencil mark on the tooth indicating the extent of overlap facilitates thismay exist in certain conditions and should be measured and recorded.
Mandibular Protrusion (reverse overjet) equal to or less than 3.5mm in Millimeters: Score exactly as
measured from the labial of the lower incisor to the labial of the upper incisor. The measurement inmillimeters is entered on the score sheet and multiplied by five (5). A reverse overbite, if present, should

DOH-Ortho (4/2022) Page 3 of 4

NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Dental Review

Handicapping Labio-Lingual Deviation (HLD) Index Report

Open Bite in Millimeters: This condition is defined as the absence of incisal contact in the anterior region.
It is measured from edge to edge in millimeters. Enter the measurement on the score sheet and multiply
by four (4). In cases of pronounced protrusion associated with open bite, measurement of the open bite
is not always possible. In those cases, a close approximation can usually be estimated.
Ectopic Eruption: Count each tooth, excluding third molars. Each qualifying tooth must be more than50% blocked out of the arch. Enter the number of teeth on the score sheet and multiply by three (3). Ifanterior crowding is present with an ectopic eruption in the anterior portion of the mouth, score only themost severe condition. DO NOT SCORE BOTH CONDITIONS. However, posterior ectopic teeth canstill be counted separately from anterior crowding when they occur in the same arch.
Anterior Crowding: Arch length insufficiency must exceed 3.5mm. Mild rotations that may react favorablyto stripping or mild expansion procedures are not to be scored as crowded. Enter five (5) points eachfor maxillary and mandibular anterior crowding. If ectopic eruption is also present in the anterior portionof the mouth, score the most severe condition. DO NOT SCORE BOTH CONDITIONS. Posterior
ectopic teeth can still be counted separately from anterior crowding when they occur in the same arch.
Labio-Lingual Spread: Use a Boley Gauge or a disposable ruler to determine the extent of deviation froma normal arch. Where there is only a protruded or lingually displaced anterior tooth, the measurement
should be made from the incisal edge of that tooth to the normal arch line. Otherwise, the total distance
between the most protruded anterior tooth and the most lingually displaced anterior tooth is measured.
The labio-lingual spread probably comes close to a measurement of overall deviation from what would
have been a normal arch. In the event that multiple anterior crowding of teeth is observed, all deviations
from the normal arch should be measured for labiolingual spread, but only the most severe individual
measurement should be entered on the index.
Posterior Unilateral Crossbite: This condition involves two or more adjacent teeth, one of which must bea molar. The crossbite must be one in which the maxillary posterior teeth involved may either be bothpalatal or both completely buccal in relation to mandibular posterior teeth. The presence of posterior
unilateral crossbite is indicated by a score of four (4) on the score sheet. THERE IS NO SCORE FOR
BI-LATERAL CROSSBITE.

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