Diagnosis: Dental Problems (skeletal Class I, maxillary spacing, proclined incisors and deep impinging overbite)
Treatment: Braces
The insurer denied coverage for braces.
The denial is upheld.

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary spacing, proclined incisors and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage 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 attaining only 11 points on review by their internal reviewers.

Upon review of the submitted documentation, (study models were not provided for review), 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 11 points (5 points overjet, 4 points overbite, and 2 points labiolingual spread).

The coverage for braces 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 braces is not substantiated. The insurer's denial should be upheld.