Diagnosis: Occlusion.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is upheld.

The patient in question is a male with a Class I, crowded occlusion with a deep bite. The orthodontist states he has an anterior crossbite with gingival attachment loss on tooth 22. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.

Braces and Monthly Visit x 12 are not medically necessary for this patient.

There is no medical reason to correct his crowding with braces. The patient does have slightly retroclined maxillary incisors and a deep bite. However, that alone is not a medical necessity to treat. There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6mm. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.