Diagnosis: Malocclusion

Treatment braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to impacted permanent anterior. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 20 points on review by internal reviewer.

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, a Handicapping Labiolingual Deviation 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 impacted permanent anterior where extraction is not indicated. This reviewer finds this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer attained a score of 20 points on the HLD index (3 points overjet, 4 points overbite, 10 points anterior crowding, 3 points labiolingual spread).

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the braces and monthly visits is not substantiated. The insurer's denial is upheld.