Diagnosis: Dental Problems (skeletal Class II, with retruded mandible, maxillary and mandibular crowding, deep overbite and severe overjet).
Treatment: D8080 Braces.

The insurer denied coverage for D8080 Braces. The denial is overturned.

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, with retruded mandible, maxillary and mandibular crowding, deep overbite and severe overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 millimeter (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant 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 6 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 overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet the insurer and the plan criteria to justify orthodontic care.

The coverage for braces and treatment visits is considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 Braces is substantiated. The insurer's denial should be overturned.