Diagnosis: Class I molar and canine relationship
Treatment: Braces
The insurer denied the braces
The denial is upheld

The patient is a female requesting orthodontic benefits. She has a Class I molar and canine relationship.

The prior denial was due to the patient not reaching the 26 threshold on the handicapping index scale.

No, the proposed treatment is not medically necessary based upon documentation provided.
The provider stated that the patient had an "anterior crossbite", which would have been an automatic qualifier. However, the photos provided do not show any evidence of an anterior crossbite of the patient's teeth. The photos showed there are no orthodontic problems with this patient.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient