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202103-135847

2021

Healthfirst Inc.

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Upheld

Case Summary

Diagnosis: Class I skeletal relationship, class II canines,
moderate maxillary spacing, moderate mandibular
crowding, missing maxillary right first premolar,
and anterior crossbite with gingival attachment
loss (mandibular left canine)
Treatment: Braces and Monthly Visits, Pre-service
The insurer denied the Braces and Monthly Visits, Pre-service
The denial is upheld.

The patient is a male. The request is for orthodontic treatment (Braces), monthly visit, Pre-service. Per the dental clinical summary-- this patient presents with a class I skeletal relationship, class II canines, moderate maxillary spacing, moderate mandibular crowding, missing maxillary right first premolar, and anterior crossbite with gingival attachment loss (mandibular left canine).

No, the proposed treatment of orthodontic therapy, monthly visits is not medically necessary.

A crossbite is when an upper tooth/teeth are inside/palatal to the corresponding lower tooth/teeth. The presence of a crossbite is not supported by the x-rays or photos submitted. The photos do not display positioning of the mandibular left canine as noted in the dental clinical summary.

A class II canine is when the distal surface of the mandibular canine is mesial to the mesial of the maxillary canine by at the least the width of a premolar. This clinical condition is also not evident in the photos. It is not supported by the documentation.

The clinical claim of anterior crossbite and a class II canine are not evident in the photos submitted.

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