Diagnosis: Mandibular crowding
Treatment is D8080 braces, D8670 monthly visit x4
The insurer denied coverage for D8080 braces, D8670 monthly visit x4.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radio graph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior impactions in addition to Class II malocclusion, maxillary and mandibular crowding and overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anterior where extraction is not indicated on the HLD index. 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. The patient's mother is appealing the decision on behalf of the patient.

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 completes the HLD index, choosing the impacted permanent anterior criterion to justify orthodontic care. The clinical circumstance meets this criterion for approval of care.

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. 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.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the D8080 braces, D8670 monthly visit, D8670 monthly visit, D8670 monthly visit, D8670 monthly visit is overturned. Medical necessity is substantiated.