Diagnosis: Malocclusion

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, orthodontist treatment records, copies of peer reviewed literature as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite and has recommended orthodontics. The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index attaining 6 total points to support orthodontic care.

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 Labio-lingual 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 6 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 14 points on the HLD index (6 overjet, 5 overbite, 3 labio-lingual spread) which is below 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

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.

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit is not substantiated. The insurer's denial is upheld.