Diagnosis: Malocclusion

Treatment: D8080-Braces

The insurer denied coverage for D8080-Braces. The denial is upheld.

This patient is a male with malocclusion. The provider states that impinging overbite with severe soft tissue damage was not considered. In order to assess the severity of the patient's malocclusion a Handicapping Labio-Lingual Deviation (HLD) Index was utilized. Criterion for approval of braces is met in two ways; either by having one of the listed automatic qualifiers or by achieving a score of 26 or more.

The patient does not meet the medical necessity criteria. The provider noted automatic qualifying criteria of "Deep impinging overbite with severe soft tissue damage," but no evidence of this is present in the clinical photos submitted.

The patient notes no pain or handicapping conditions that are a result of his occlusion. No medical conditions are noted in medical history that would support medical necessity. The patient's clinical presentation as demonstrated through clinical photos and radiographs does not warrant coverage under automatically qualifying condition. The patient's HLD score was 18 which is below the required 26.

Based on the above, the medical necessity for the requested code D8080- Braces (comprehensive orthodontic treatment of the adolescent dentition) is not substantiated. The insurer's denial is upheld.