Diagnosis: Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index, attaining 20 total points to support orthodontic care.

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, having attained a score of 10 points on the HLD index.

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 does not claim an automatic qualifying condition
and completes the second portion of the index, arriving at 20 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 20 points on the HLD index (7 points overjet, 3 points overbite, 10 points anterior crowding), which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

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

Based on the above, the medical necessity for the D8080 braces is not substantiated. The insurer's denial is upheld.