Diagnosis: Impacted maxillary canines.
Treatment: D8070 braces and D8670 monthly visits x 4.

The insurer denied coverage for D8070 braces and D8670 monthly visits x 4. The denial is overturned.

This is a female child, who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics, due to the patient's impacted maxillary canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining only 17 points on review by internal reviewers.

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 HLD index is utilized. This index provides 6 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Thus, the coverage for D8070 braces and D8670 monthly visits x 4 is considered medically necessary for this patient.