Diagnosis: Class I malocclusion.
Treatment: D8080 Braces & D8670 Follow-Up Visits.

The insurer denied the D8080 Braces & D8670 Follow-Up Visits. The denial is overturned.

The patient is a female. The request is for orthodontic benefits. The patient has a Class I malocclusion. She has multiple anterior teeth in crossbite (reverse bite) and severe crowding in the lower jaw. The denial was due to the Salzmann index not being more than 25.

Yes, the proposed treatment is medically necessary.

The patient has severe crowding in her lower jaw. This has caused several areas of crossbite, where her lower teeth are in front of her upper teeth. This is not a good situation. This has also caused some gum recession from the gumline of her lower canines. This "anterior crossbite with gum recession" is an "automatic qualifier," according to the handicapping index scale. Over time, the teeth will bang together during the chewing cycle, causing trauma, fractures and/or loosening of teeth. This most probably will contribute to temporomandibular joint (TMJ) issues in the future because the teeth cannot mesh properly without causing undue strain on the TMJ and the out of place teeth. In order to prevent much trauma in the future to her oral structures, this patient needs orthodontic treatment to correct her very poor bite. This case has medical necessity.

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