Diagnosis: Dental Problems-Brace.
Treatment: Dental/Orthodontic Procedure.
The insurer denied braces and adjustments for braces for medical necessity.
The denial was upheld in whole.

The patient is a male with a Class I occlusion with a 4-millimeter (mm) overbite and 6 mm overjet. He has moderate maxillary and mandibular crowding. The provider states he has blocked out mandibular second molars. He has treatment planned for 24 to 30 months of orthodontics with extraction of first premolars to correct his malocclusion.
At issue is the medical necessity of braces and adjustments for braces.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Braces and adjustments for braces, is not medically necessary for this patient.
There is no medical reason to correct the patient's malocclusion with braces. While the patient has moderate crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. His overbite is slightly high but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is any soft tissue damage on this patient.
The patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. The provider states that the patient's mandibular second molars are blocked out, but they have a path of eruption according to the provided panoramic radiograph.
Therefore, the requested health service/treatment of Braces and adjustments for braces, is not medically necessary for this patient.