Fa-25 Handicapping Labiolingual Deviation (Hld) Index Report Form
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2ewlett ackard
– Nevada Medicaid and Nevada Check Up
Handicapping Labiolingual Deviation (HLD) Index Report
Provider Name: ____________________________________ NPI: _____________________
Recipient Name: ___________________________________ Recipient ID: __________________________
Instructions: (Assistance from a recorder/hygienist is recommended.)
1. Position the recipient’s teeth in centric occlusion.
2. Record all measurements in the order given and round off to the nearest millimeter (mm).
3. ENTER A SCORE OF “0” IF A CONDITION IS ABSENT.
4. Enter the requested provider and recipient information above. Provider must sign and date at the bottom.
Condition
HLD Score
Cleft palate deformities (Indicate an “X” if present and score no further.)
Deep impinging overbite WHEN LOWER INCISORS ARE DESTROYING THE SOFT TISSUE
OF THE PALATE (Indicate an “X” if present and score no further.)
Individual anterior teeth crossbite WHEN DESTRUCTION OF SOFT TISSUE IS PRESENT
(Indicate an “X” if present and score no further.)
Attach description of any severe traumatic deviations. For example, loss of a premaxilla
segment by burns or by accident; the result of osteomyelitis; or other gross pathology.
(Indicate an “X” if present and score no further.)
Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with
reported masticatory/speech difficulties. (Indicate an “X” if present and score no further.)
Overjet in mm
Overbite in mm
Mandibular protrusion in mm
_____ x 5 = _____
Open bite in mm
_____ x 4 = _____
If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe
condition. Do not score both conditions.
rd
Ectopic eruption: Count each tooth, excluding 3
molar.
_____ x 3 = _____
Anterior crowding: Score one point for MAXILLA, and/or one point for MANDIBLE; two points
_____ x 5 = _____
maximum for anterior crowding.
Labiolingual spread in mm
If the recipient has a posterior unilateral crossbite; involving two or more adjacent teeth, one of
which is a molar, enter/score a “4” for this item.
Total Score: _____
If a recipient does not score an HLD Index of 26 or above, he/she may be eligible for services under the Health Kids (EPSDT)
exception. To request a Health Kids exception, attach appropriate documentation for each of the following eight areas:
1.
Principal diagnosis and significant associated diagnosis
2.
Prognosis
3.
Date of onset of the illness or condition and edology if known
4.
Clinical significance or functional impairment caused by the illness or condition
5.
Specific services to be rendered by each discipline and anticipated time for achievement of goals
6.
Therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals
7.
Extent of previous services that were provided to address the illness/condition and results of the prior care
Any other documentation available which may assist ewlett ackard
8.
in making the determination
Provider Signature: ___________________________________________________ Date: ___________________
FA-25
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