Diagnosis: Malocclusion

Treatment D8080 braces

The insurer denied coverage for D8080 braces

The denial is upheld

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 identified several clinical findings including overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index attaining 21 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 13 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after HLD Index. 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 21 points to justify orthodontic
care. This reviewer concurs with the index completed by the orthodontist attaining a total of 21 points on the HLD index 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.

Uphold denial as 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.

In this case the patient's own orthodontist completed HLD index total score of 21 points remains below threshold of 26 points to justify orthodontic care.

D8080 braces is not considered medically necessary for this patient.

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 is upheld. Medical Necessity is not substantiated.