Diagnosis: Maxillary and Mandibular Crowding, Excessive Overjet

Treatment D8080 braces and D8670 monthly visit x (times) 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned

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 skeletal Class II, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage.

Upon review of the submitted documentation, 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 an HLD 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 deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Denial of coverage for D8080 braces and D8670 monthly visit x 12 is overturned. Medical necessity is substantiated.