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Orthodontia Braces denials: what the review data shows
Independent reviewers have decided 17 published cases where an insurer denied Orthodontia Braces — and they overturned the insurer 35.3% of the time. A denial for Orthodontia Braces is a starting position, not a final answer.
Published decisions
17
2001–2026
Overturned
35.3%
6 denials reversed
Conditions behind orthodontia braces denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Overbite Underbite | 6 | 33.3% |
Typical time to a decision
21 days
Most land between 15 and 23 days
Handled as urgent
5.9%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for comprehensive orthodontic treatment of adolescent dentition. The enrollee has bilateral severely impacted maxillary cuspids, transversely constricted dental arches, a 100% deep and impinging overbite, and ankyloglossia with resultant tongue-thrust habit. The provider has recommended orthodontic treatment to provide the best chance of developing a healthy, functional occlusion; including attempting to successfully bring his ectopically impacted cuspids into proper occlusion. The provider indicates there is a possibility of root damage to the adjacent teeth due to the impacted cuspids, and a possibility the impacted cuspids could become ankylosed. Upon review of the record, it is evident the enrollee exhibits a significant malocclusion.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthodontic treatment. The submitted documentation supports that the requested services are dentally necessary. The Handicapping Labio-Lingual Deviation (HLD) Index is one of four commonly used American and European orthodontic treatment need indices. These indices were devised to minimize the subjectivity associated with the diagnosis, referral and complexity assessment of malocclusion. The HLD Index, as with other indices, has a score component to determine orthodontic need as well as conditions that automatically qualify for dental necessity. One automatic qualifier is an overjet greater than 9mm. When using the HLD Index, if one of the automatic qualifiers is present, the examiner is to stop scoring.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
An enrollee has requested reimbursement for dental braces. The submitted documentation does not support the medical necessity of the services at issue. Colleagues have studied the relationship between malocclusion and quality of life in adolescents. Their study concluded that malocclusion and orthodontic treatment do not appear to affect general or oral health quality of life to a measurable degree. This is despite subjective and objective evidence for improved appearance, oral function and health and social well-being. To assess the need for orthodontic treatment, there are many objective tools to quantify the degree of handicap caused by the malocclusion. Orthodontic treatment need indices are used to rank the malocclusion.
Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old male enrollee has requested authorization and coverage for orthodontic treatment including D0330 (panoramic x-ray), D0340/D0350 (cephalometric images), D0470 (diagnostic casts), D8080 (comprehensive orthodontic treatment), D8670 (periodic orthodontic treatment), D8680 (orthodontic retention) for treatment of the enrollee’s dental issues. Findings: The physician reviewer found that as the need for orthodontic treatment can involve subjective assessments, there have been several objective tools developed as a means of comparing need for treatment. One such tool is the HLD. With the HLD, a score typically greater than 25 qualifies for treatment as a severe need. In this case, the corrected score was computed at 20, which is well under the threshold for treatment.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Orthodontia Braceswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.