Diagnosis: Dental Problems (skeletal Class II malocclusion, maxillary spacing and diastemas, and excessive overjet and overbite).
Treatment: D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12. The denial is upheld.

This patient is a female child, who was evaluated for orthodontic treatment. The orthodontist recommended comprehensive orthodontics, due to skeletal Class II malocclusion, maxillary spacing and diastemas, and excessive overjet and overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying conditions of deep impinging overbite with severe soft tissue damage and overjet greater than 9 millimeters with incompetent lips or reverse overjet greater that 3.5 millimeters with reported masticatory/speech difficulties, to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index.

Upon review of the submitted documentation 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, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labiolingual Deviation Index. 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 claims an automatic qualifying condition of deep, impinging overbite with severe soft tissue damage and overjet greater than 9 millimeters with incompetent lips or reverse overjet greater than 3.5 millimeters with reported masticatory/speech difficulties. This reviewer finds that these automatically qualifying conditions are not met and do not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the Handicapping Labio-Lingual Deviation (HLD) index of the insurer, attaining 14 points (5 points overjet, 6 points overbite, 3 points labiolingual spread).

The coverage for D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.

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 visit x 12 is not substantiated. The insurer's denial should be upheld.