Diagnosis: Crowding; crossbite
Treatment: Full Braces and Monthly Adjustment Visit
The insurer denied the Full Braces and Monthly Adjustment Visit
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (braces) and monthly visits. Per the provider's dental clinical summary, the patient presents with moderate maxillary and mandibular crowding, complete buccal crossbite-maxillary left first premolar, anterior crossbite with gingival attachment loss (mandibular right canine).

The health plan denied coverage for the claim because, "it was not medically necessary," and that the info submitted did not support a crossbite with gingival attachment loss.

The provider appealed the claim based on his diagnosis of the crossbite.

Yes, the requested braces and monthly visits are medically necessary.
This patient presents with two crossbites. The complete buccal crossbite (maxillary first premolar) is so severe that this tooth does not occlude (touch) the opposing tooth that it is meant to engage during the process of chewing.

The overall malalignment and crowding will have a very detrimental effect on the patient's dentition. This will affect the level of oral hygiene that the patient will be able to achieve, and lead to decrease function. More specifically, proper speech, the ability to chew and digest food effectively are all compromised as a result of the malalignment.

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

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
Considering the severity of the malalignment as supported by the photos and the x-rays, the ramifications of the patient's overall dental health will be compromised and diminished if treatment is not received.