Diagnosis: Malocclusion

Treatment: Orthodontics

The insurer denied the orthodontic care. The denial was upheld

The patient has skeletal class I, normal vertical growth pattern, permanent dentition, class II canines, moderate maxillary and mandibular crowding, moderately excessive overjet, impacted molars and deep impinging overbite with severe soft tissue damage.

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, a Handicapping Labiolingual Deviation Index is used. 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 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, and does not support comprehensive orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 22 points (3 points overjet, 6 points overbite, 10 points anterior crowding, 3 points labiolingual spread).
In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.