Diagnosis: Malocclusion

Treatment D8080 braces and D8670 monthly visit (x (times)8),

The insurer denied coverage for D8080 braces and D8670 monthly visit (x8),

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, montage of extraoral and intraoral clinical images, narrative letters, as well as insurer correspondence, and NYS (New York State) Medicaid Dental guidebook, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior (#11) where extraction is not indicated.

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
impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic. This reviewer concurs with the findings of the insurer of attaining 21 points on the HLD index (3 points overjet, 4 points overbite, 10 points anterior crowding, 4 points labiolingual spread).

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.

Each of the 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.

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit (x8) is upheld. Medical Necessity is not substantiated.