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202303-160809

2023

Fidelis Care New York

Medicaid

Dental Problems

Dental/ Orthodontic Procedure

Medical necessity

Overturned

Case Summary

Diagnosis: Blocked teeth.
Treatment: D8080 Braces and D8670 Monthly Visits.
The insurer denied the D8080 braces and D8670 monthly visits.
The denial is overturned.

The patient is a teenaged female requesting orthodontic benefits including monthly visits. The patient has a class I malocclusion with moderate maxillary and mandibular crowding. The prior denial was due to a handicapping score of 18.

The proposed treatment is medically necessary.

The patient has both upper permanent canines out of position. They are "blocked" out of the dental arch, meaning that there is not enough room for them to be in their proper positions. Because of this, the upper canines [teeth # (number) 6 and #11] do not touch the lower canines like they are supposed to. Without this connection, there can be no "canine guidance", which is when the lower canines glide along the backs of the upper canines during the chewing cycle. When there is no canine guidance, the rest of the teeth do not mesh together harmoniously. Rather, they grind and bang together traumatically. Without canine guidance, over time there will be teeth that are traumatized, fractured and/or loosened. There can also be temporomandibular joint (TMJ) problems developing. Orthodontic treatment is medically needed for this patient to correct the malocclusion. The monthly visits are also needed to make sure the treatment is progressing properly. The prior denial of the teeth not being out of position is incorrect.

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