Diagnosis: Anterior Crowding, Overjet and Overbite.
Treatment: D8080 braces and D8670 monthly visits x 14.

The insurer denied the D8080 braces and D8670 monthly visits x 14. The denial was upheld.

This is a patient who consulted an orthodontist for orthodontic treatment. A series of diagnostic tests were performed including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. Multiple orthodontists identified several clinical findings including anterior crowding, overjet and overbite and have recommended orthodontics. Two separate orthodontists each completed the patient's HLD index attaining 33 total points and 26 and 30 points, respectively, to support orthodontic care.

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, 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 orthodontists did not claim an automatic qualifying condition and did not complete the second portion of the index arriving at 26, 30 and 33 points to justify for orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 20 points on the HLD index (3 points overjet, 3 points overbite, 5 points mandibular protrusion, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support for orthodontic care.

The health plan acted reasonably 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 visits x 14 is not substantiated. The insurer's denial should be upheld.