Diagnosis: Dental Problems.
Treatment: Dental/Orthodontic Procedure.
The insurer denied Braces and monthly visits.
The denial is upheld.

The patient is a male with a Class I occlusion with appropriate overbite and overjet. He has maxillary and mandibular spacing. He has treatment planned for orthodontics to correct his malocclusion. His health plan has denied the request on the basis that treatment is not medically necessary. The family is appealing this ruling.
At issue is the medical necessity of Braces and monthly visits.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Braces and monthly visits is not medically necessary for this patient.
The patient has some minor spacing. His overbite is appropriate and there is no indication of damage to the incisors. His cephalometric radiograph showed he does not have a traumatic deep bite. There is no indication that there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned, it would provide an aesthetic improvement, but it would not create a medical improvement to the patient's health.
Therefore, the requested health service/treatment of Braces and monthly visits is not medically necessary.