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202106-139106

2021

Affinity Health Plan

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Overturned

Case Summary

Diagnosis: Cross-bite, shallow overbite, and overjet
Treatment: D8080 Braces (Pre-service)
The insurer denied the D8080 Braces (Pre-service)
The denial is overturned.

The patient is a male requesting dental benefits for Orthodontic treatment (Braces). The patient presents with a Class I molar relationship, anterior cross-bite (UR3 [upper right 3]/LR3 [lower right 3]), shallow overbite and overjet.

The patient had clinical consultation. Orthodontic records were made, photos were taken, and a treatment plan was created.

Yes, the Braces are medically necessary.

As evident in the photos and as stated in the clinical findings on the HLD (Handicapping Labio-Lingual Deviation) index, the patient presents with an anterior crossbite in (UR3 [upper right 3]/LR3 [lower right 3]) area. This is an automatic qualifier for orthodontic treatment as per the HLD (Handicapping Labio-Lingual Deviation) index.

Furthermore, anterior crossbites can lead to difficulty with speech, proper chewing and the inability to maintain proper hygiene.

Therefore, given the above, the Braces are medically necessary.

Non-treatment of this condition, can lead to difficulty with speech, proper chewing and the inability to maintain proper hygiene, therefore; this will only contribute to long term problems with the patient's overall dentition.

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