Diagnosis: Anterior crossbite with gingival attachment loss

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity

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, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report modeled after the Handicapping Labiolingual Deviation Index. 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. This reviewer concurs with the HLD index of the insurer attaining 24 points (3 overjet, 4 overbite, 10 mandibular protrusion, 5 anterior crowding and 2 labiolingual spread).

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. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The patient's clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. As presented, there was sufficient evidence to support that D8080 (braces) and D8670 (monthly visit) were not considered medically necessary for the patient's condition.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.