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, and open bite and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 16 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 on the HLD index attaining 21 points by internal reviewers.

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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 16 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining at total of 16 points on the HLD index (6 overjet, 8 open bite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required/or orthodontic approval.

In this case the patient's own orthodontists complete HLD index total score of 16 points remains below the threshold of 26 points to justify orthodontic care.

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

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces and monthly visits services is not substantiated.