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, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the handicapping labio-lingual deviation (HLD) index, attaining 26 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 used. 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 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer, attaining a total of 18 points on the HLD index (4 overjet, 12 open bite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Deviation 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 cited below.

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Braces and monthly visits are not considered medically necessary for this patient.

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

The insurer's denial of coverage for braces and monthly visits is upheld. Medical necessity is not substantiated.