Diagnosis: Impacted canine (maxillary left canine-tooth #11).
Treatment: D8080 Braces, D8670 Monthly Visit.
The insurer denied the D8080 Braces, D8670 Monthly Visit.
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic treatment (braces) and monthly visits. Per the Provider's dental clinical exam--the patient has an impacted canine (maxillary left canine-tooth #11).

The health plan denied the claim because the patient did not score a 26, the score necessary for orthodontic treatment approval on the Handicapping Labio-Lingual Deviation (HLD) Index Report. The Provider appealed the case based on the diagnosis of an impacted canine, an automatic qualifier for orthodontic treatment (braces) per the Handicapping Labio-Lingual Deviation (HLD) Index Report.

The proposed treatment of orthodontic therapy (braces) and monthly visits are medically necessary.

As supported by the x-rays submitted, the maxillary left canine is impacted with no visible space to allow for normal eruption. This will require orthodontic intervention to bring this tooth into occlusion.

Per the Handicapping Labio-Lingual Deviation Index Report - impacted permanent anterior teeth where extraction is not indicated is an automatic qualifier for orthodontic therapy (braces).