Diagnosis: Dental Disorder.
Treatment: Braces and Monthly Visits.
The insurer denied the Braces and Monthly Visits.
The determination is upheld.

The patient has a Class I occlusion with 4 millimeter (mm) overbite and 4 mm overjet. She has severe maxillary and mandibular crowing. She is treatment planned for 30-36 months of orthodontics with extraction of all four first premolars to correct her malocclusion.
At issue is the medical necessity of braces and monthly visits.

The braces and monthly visits are not medically necessary. A Handicapping Labio-Lingual Deviation (HLD) score of 26 or above in the absence of an autoqualifying condition would qualify as medically necessary. This reviewer scored the patient at a 23 (4 overjet, 4 overbite, 10 maxillary and mandibular anterior crowding, and 5 labio-lingual spread), and confirm the absence of an autoqualifying condition as described by the provided HLD index form.
Discounting the HLD score, there is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.(1) However, this patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient's overjet is more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 millimeters (mm).(3) If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. The requested orthodontic treatment is not medically necessary.