Orthodontia Braces denials in California external review

What the reviewers wrote

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

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.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Orthodontia Braces, then check the rights and deadlines that apply to your plan.