Diagnosis: Anterior Crossbite.

Treatment D8080 braces and D8670 monthly visit.

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

The denial is upheld.

The dental director states that the Handicapping Labio-Lingual Deviation (HLD) index is 14. The provider states that the patient automatically qualifies as there is an anterior crossbite. In order to qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no crossbite evident and no clinical attachment loss and recession of the gingival margin evident on the photographs. The different gingival levels are due to the malposition of the teeth and not due to recession.

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 meet the requirements. There is no increased overjet, traumatic overbite, anterior crossbite, impacted teeth or crossbites associated with mandibular displacements.

The guidelines for braces are not met.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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