This is a patient with maxillary and mandibular spacing. He has approximately 7 millimeter (mm) overjet and 4 millimeter (mm) overbite. Teeth A, B, C, M and R are still present and there are several unerupted permanent teeth, including all second molars. There is no orthodontic diagnosis or treatment plan provided, so determination will be made on diagnostic records. The treatment was denied due to a lack of medical necessity, and the family is appealing this decision. At issue is the medical necessity of braces and 12 monthly visits.
The health plan's determination is upheld. While the patient has spaces between the teeth and a significant overjet, there is no indication supplied of a functional impairment due to the position of his teeth. Treatment of his bite at this age will lead to an extended time in braces. There are several unerupted permanent teeth, but it appears there is enough room for them to emerge, which is likely as the patient is young. The teeth are not so crowded that they would be prevented from erupting, which left untreated could damage the roots of other permanent teeth (1) leading to more invasive procedures.