Diagnosis: Dental Problems (overjet and overbite).
Treatment: Braces and monthly office visits.

The insurer denied coverage for braces and monthly office visits.

The denial is upheld.

This is a female child who presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including overjet and overbite and has recommended orthodontics. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 6 total points to support orthodontic care. 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 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 6 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 10 points on the HLD index (3 points overjet, 4 points overbite, 3 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note, in this case, the patient's own Orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes 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.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The coverage for braces and monthly office visits is not considered medically necessary for this patient.

The insurer's denial of coverage for braces and monthly office visits is upheld. Medical necessity is not substantiated.