Diagnosis: Crossbite of individual anterior teeth.
Treatment: Orthodontic treatment (braces).

The insurer is denied coverage for orthodontic treatment (braces).

The denial is upheld.

This female patient who was evaluated for orthodontic treatment. A clinical examination and analysis consisting of a dental and jaw evaluation revealed the following findings: skeletal Class I; normal vertical growth pattern; permanent dentition; Class II canines; mild maxillary spacing; mild mandibular spacing; and anterior crossbite with gingival attachment loss (mandibular right canine). The following automatic qualifier was chosen on the patient's Handicapping Labio-Lingual Deviation (HLD) Index report: crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The physician is requesting authorization for orthodontic treatment (braces) and periodic treatment visits for the patient.

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, an 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 19 points (9 overjet, 3 overbite, 3 ectopic eruption, 4 labiolingual spread).

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the orthodontic treatment (braces) is upheld. The medical necessity is not substantiated.