Diagnosis: Handicapping labio-lingual deviation (HLD) score was 17.

Treatment: D8080 braces and D8670 monthly visit x 12

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

The denial is overturned.

This male patient has a history of skeletal Class I, Class II canines, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite.

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, and 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.

ln 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 met and does support comprehensive orthodontic care. ln this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.