Diagnosis: Overjet

Treatment D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

This is a teenage female with no documented history who presented to the Orthodontist's office for an evaluation.

Based on the submitted documentation there does not appear to be any crowding or spacing in the upper and lower anterior. The overjet appears to be normal.

Per An Introduction to Orthodontics, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction:
1) Increased Overjet
2) Increased traumatic Overbites
3) Anterior crossbites causing decreased periodontal support
4) Unerupted impacted teeth (where there is danger of pathology)
5) Crossbites associated with mandibular displacements

Per the clinical records, the patient does not have any of the above problems. There is no increased overjet or overbite noted or crossbites. There is not a high need for orthodontic treatment. The health plan acted reasonably with sound medical judgment.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.