Diagnosis: Crowding
Treatment: D8080 Braces and D8670 Monthly Visit (x12)

The insurer denied the D8080 Braces and D8670 Monthly Visit (x12).
The denial is overturned.

The patient is a male. The request is for orthodontic treatment (Braces) and monthly visits.

Per the Provider's dental consultation, the patient presents with class I skeletal relationship, class II canines, moderate maxillary crowding, severe mandibular crowding, deep bite, moderately excessive overjet, anterior cross bite with gingival attachment loss (Mandibular left Canine).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report, the score necessary for the approval of orthodontic treatment (Braces).

The provider appealed the case based on the diagnoses, particularly the anterior crossbite with gingival attachment loss--an automatic qualifier for orthodontic treatment per the HLD (Handicapping Labio-Lingual Deviation) Index Report.

Yes, the Braces and monthly visits are medically necessary.
As supported by the photos and X-rays and as stated in the Provider's dental clinical summary, the patient presents with severe mandibular and moderate maxillary crowding. He also has anterior crossbite with gingival attachment loss on mandibular left Canine.

The crowding and crossbite (mal alignment) can affect the patient's ability to chew food properly. It also affects proper speech and the ability to maintain proper hygiene and can lead to gingivitis/inflammation and gum disease.

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

No, the Health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If the patient's conditions are left untreated, the complications of decreased proper function as it relates to chewing, speech and compromised oral hygiene can only lead to more dental problems in the future.