Diagnosis: Crowding
Treatment: Comprehensive orthodontic treatment (Braces)
The insurer denied the Comprehensive orthodontic treatment (Braces).
The denial is upheld.

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces). Clinical summary indicates that the patient has a class I normal molar relationship and moderate crowding in both arches.

No, the Comprehensive orthodontic treatment is not medically necessary.

While the clinical exam summary indicates that the patient has moderate crowding in both arches, the degree of severity is not supported in the x-rays and photos. The patient has a class I normal molar relationship, and the records do not indicate that the patient has any significant difficulty with eating, breathing or with her speech.

Furthermore, although it is stated in the appeal notes that the patient is biting her lips and cheeks upon chewing; this is not substantiated in the photos. Typically, a significant chronic trauma from occlusion like this would result in substantial visible irritation (redness/swelling) and possible ulceration.