202103-136308
2021
Healthfirst Inc.
Medicaid
Dental Problems
Dental/ Orthodontic Procedure
Medical necessity
Overturned
Case Summary
Diagnosis: Dental Problems/Other-brace and monthly visits.
Treatment: Dental/Orthodontic Procedure.
The health plan denied the request for braces as not medically necessary.
The health plan's determination is overturned.
The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.
At issue is the medical necessity of the requested health service/treatment of braces.
I overturn, in whole, the health plan's denial of medical necessity.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.[1,2,3]
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.