Diagnosis: Severe crowding, and impacted canine (#6)

Treatment: D8080 (braces)

The insurer denied coverage for D8080 braces.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as narrative letters, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding, and impacted canine (number [#] 6). The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 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, attaining only 13 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient.

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, a Handicapping Labio-Lingual Deviation 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 claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. 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 insurer and plan criteria to justify orthodontic care.

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

D8080 braces considered is medically necessary for this patient.

The insurer's denial of coverage for D8080 braces is overturned. Medical necessity is substantiated.