Diagnosis: Crossbite.
Treatment: D8080 Braces, Pre-service.

The insurer denied the D8080 Braces.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (braces). The patient presents with a class I molar relationship, severe upper and lower arch crowding, anterior crossbite with gingival attachment loss, impacted upper left UL5 (upper left 2nd premolar), and posterior crossbite on left.

Orthodontic records have been made - x-rays, photos; completed clinical consultation.

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) index needed to approve orthodontic treatment. The provider appealed based on the multiple diagnoses, particularly the anterior crossbite with gingival attachment loss as this is an automatic qualifier for orthodontic treatment per the Handicapping Labio-Lingual Deviation (HLD) index.

Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary.
The patient presents with several dental malalignment conditions; severe crowding in both the upper and lower arches, an impacted upper left second premolar, anterior crossbite with gingival attachment loss lower left canine. These conditions are all supported in the x-rays and photos submitted.

This malalignment has the ability to affect the quality of the patient's speech, chewing and ability to maintain proper hygiene. The potential complications can give rise to inflammation of the gums and eventually gum disease.

Given the severity of these conditions, the lack of orthodontic intervention will leave the patient at risk for further shifting of the teeth and deterioration of the patient's overall dentition.