Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Class I occlusion with a 4-millimeter (mm) overbite and 4-millimeter (mm) overjet. The patient has minor maxillary and mandibular crowding. The patient is in the mixed dentition with tooth 20 yet to erupt. The patient's treatment plan is for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of the requested services.
There is no medical reason to correct his malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. However, this patient presents with none of those conditions. Aligning his teeth will not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. Moreover, if his teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.