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202210-154680

2022

Affinity Health Plan

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Overturned

Case Summary

Diagnosis: Class II crowding
Treatment: Braces and monthly visits
The insurer denied the braces and monthly visits.
The health plan's determination is overturned.

The patient in question is a female with a diagnosis of Class II crowding. Tooth # (number) 29 is impacted and blocked out of the arch. Tooth #6 is blocked out to the labial. The patient was treatment planned for 30-36 months of orthodontics to create space to bring teeth 6 and 29 into the arch.

Braces and monthly visits are medically necessary.

Impacted teeth can lead to bone defects of the adjacent erupted teeth. It is a generally accepted practice guideline to address the impacted tooth by attempting to surgically remove it or to gain space to allow the impacted tooth to erupt.

Impacted teeth can cause damage to the roots of adjacent teeth, which could lead to expensive restorative treatments. Braces and monthly visits are medically necessary to correct this patient's issues.

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