This is a patient is a patient with a skeletal Class I occlusion, class II cupids, moderate maxillary and mandibular crowding, right posterior crossbite, mild overbite and severe overjet. The proposed treatment is braces with extraction of first premolars for 24-30 months. The issue under review is the medical necessity for braces.
The health plan's determination is upheld.
The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 21 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this patient.