Diagnosis: Dental Problems.
Treatment: Dental/Orthodontic Procedure.
The insurer denied braces for medical necessity.
The denial was upheld.

The patient is a female with moderate maxillary and mandibular crowding. The narrative states number (#) 6 and #11 are blocked out. The patient has a class I occlusion with 4-millimeter (mm) overjet and 10% overbite. The patient has treatment planned for orthodontics to align the teeth and correct the bite, but the treatment plan was denied for lack of medical necessity.
At issue is the medical necessity of Braces.

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

The requested health service/treatment of Braces is not medically necessary for this patient.
While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. Teeth #6 and #11 are crowded but they have erupted successfully. There are no indications of gingival recession or pathology from the tooth position of these teeth. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. The patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. The patient has a 4 mm overjet, but research shows an overjet does not affect oral health related quality of life unless it is greater than 6 mm. If the patient's teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health.
For these reasons the requested treatment of braces, is not medically necessary.