Diagnosis: Overjet
Issue under review: Braces and monthly visits

Determination:
The Braces and monthly visits are medically necessary.

The patient is a female child. The request is for orthodontic benefits as well as benefits for monthly follow ups.

The patient has nine millimeters (mm) of horizontal overjet. This means her upper front teeth stick out nine mm from the front of her lower front teeth. This is excessive and subjects the patient's front teeth to trauma over time. The probability of fracturing all or part of these teeth is high due to their excessive prominence. Orthodontic treatment is medically necessary to get these teeth back into their proper position so they are not prone to breaking.