Diagnosis: Dental problems (skeletal Class I malocclusion, class II canines, maxillary and mandibular crowding, posterior crossbite, excessive overjet, blocked out mandibular molars).
Treatment: Braces.
The insurer denied coverage for braces. The denial is overturned.

This is a female child who presented evaluation for orthodontic care. The orthodontist identified skeletal Class I malocclusion, class II canines, maxillary and mandibular crowding, posterior crossbite, excessive overjet, blocked out mandibular molars and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points. 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 having attained a score of 16 points on the HLD index.

It is evident that the patient exhibits a significant 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 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 did not claim an automatic qualifying condition and completed the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 28 points on the HLD index (4 overjet, 3 overbite, 9 ectopic eruption, 5 anterior crowding, 3 labiolingual spread 4 posterior unilateral crossbite) which is above the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.

Peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for braces is substantiated. The insurer's denial is overturned.