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202001-124924

2020

Fidelis Care New York

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Upheld

Case Summary

Diagnosis: Overjet, Overbite, Ectopic Eruption and crowding

Treatment: D8080 (braces) and D8670 (monthly visit x 4)

The insurer denied D8080 (braces) and D8670 (monthly visit x 4). The denial was upheld.

This is a male patient who consulted an orthodontist for orthotic treatment. Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images. It was determined that the patient had overjet, overbite, ectopic eruption and crowding; recommendations for orthodontic treatment was made. Handicapping Labio-Lingual Deviations (HLD) index was performed attaining 26 total points.

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the use of a Handicapping Labiolingual Deviation 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 12 points on the HLD index (4 overjet, 5 overbite, and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

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

Based on the above, the medical necessity for D8080 (braces) and D8670 (monthly visit x 4) is not substantiated. The insurer's denial is upheld.

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