Diagnosis: Malpositioned Teeth.
Treatment: Braces.
The health plan denied the braces.
The determination is overturned.

The patient is a male. He has a Class I malocclusion with moderate crowding and protrusive maxillary incisors. He has an 8-millimeter (mm) overjet and 5-mm overbite. He is treatment planned for 24-30 months of orthodontics with extraction of four first premolars to correct the crowding and protrusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary.

At issue is the medical necessity of braces.

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

The requested health service/treatment of braces is medically necessary for this patient. There is strong medical evidence that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.[1] Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has.[2] For these reasons orthodontic treatment is deemed medically necessary.