Diagnosis: Crossbite.
Treatment: D8080 Braces and D8670 Monthly Visit.

The insurer denied the D8080 Braces and D8670 Monthly Visit. The denial is overturned.

The patient is a female. The request is for orthodontic benefits. The health plan denied coverage due to no "auto qualifiers" and a handicapping index of only 19.

Yes, the braces and monthly visits are medically necessary.

Both of the patient's lower canines, 22 and 27, are in crossbite with the upper lateral incisors. There is also gingival recession on the canines. These are two "automatic qualifiers" for orthodontic benefits. Both the lower canines are anterior teeth, and when they are in crossbite (i.e., reverse bite) with gum recession, the auto qualifier clause rules.

Therefore, given the above, the braces and monthly visits are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.