Diagnosis: Dental Problems (skeletal Class II malocclusion, maxillary and mandibular crowding, retruded mandible, excessive overjet, maxillary incisor protrusion, buccal crossbite of maxillary premolars and blocked out mandibular second molars).
Treatment: D8080 braces and treatment visits.

The insurer denied coverage for D8080 braces and treatment visits. The denial is overturned.

This patient is a male child, who presented for evaluation for orthodontic care. The orthodontist identified skeletal Class II malocclusion, maxillary and mandibular crowding, retruded mandible, excessive overjet, maxillary incisor protrusion, buccal crossbite of maxillary premolars and blocked out mandibular second molars. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 35 total points. 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.

Upon review of the submitted documentation (study models were not provided for review) 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 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 does not claim an automatic qualifying condition and completes the second portion of the index, arriving at 35 points to justify orthodontic care. This reviewer concurs with the HLD index completed by the orthodontist, attaining a total of 35 points on the HLD index (5 overjet, 5 overbite, 12 ectopic eruption, 10 anterior crowding, 3 labiolingual spread), which is above the threshold of 26 points to support orthodontic care for this patient.

D8080 braces and treatment visits are considered medically necessary for this patient.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces and treatment visits is substantiated. The insurer's denial should be overturned.