Diagnosis: Crossbite, Malocclusion
Treatment: Braces and monthly visits
The health plan denied the braces and monthly visits.
The health plan's determination is overturned.

The patient is a male with an anterior crossbite. He presents with a Class II malocclusion with crowding in the maxilla and mandible. He has a posterior crossbite on the right. He has treatment planned for 30-36 months of orthodontics to address the crowding and crossbites.

At issue is the medical necessity of braces and monthly visits.

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

The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated, the damage that will occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the treatment is deemed medically necessary.