Diagnosis: Malocclusion.
Treatment: D8080 Braces, D8670 monthly visits, D8680 Retainer.
The insurer denied coverage for D8080 Braces, D8670 monthly visits, D8680 Retainer.
The denial is overturned.

This is a teenager under the care of an orthodontist for the treatment of his dental malocclusion. The patient has an anterior crossbite, a very narrow maxilla, impacted premolar, and generalized crowding. The impacted premolar is supernumerary. It is noted the patient was given a Handicapping Labio-Lingual Deviation (HLD) of 19 by the insurer, which doesn't qualify. The request is for D8080 Braces, D8670 monthly visits, D8680 Retainer, which is under review.

The HLD includes an overjet of four millimeters (mm) and an overbite of three millimeters. The patient's teeth, 9 and 10 are ectopic in eruption, as they are in complete crossbite. There is crowding in both the maxillary and mandibular arches for a 10 and the labiolingual spread is five millimeters for a total HLD score of 28, which meets policy.

Therefore, the request for D8080 Braces, D8670 monthly visits, D8680 Retainer is medically necessary and is approved.

"Orthodontics seeks to achieve esthetic and functional improvement via mechanical therapy that moves teeth into a more ideal position. Determining the ideal dental position for each patient depends on several factors, such as the facial profile, facial balance, and aesthetic concerns..."

It is important to note that surgical treatment of malocclusion is typically only recommended in severe cases, and other treatment options, such as braces, may be tried first. A thorough evaluation by an orthodontist or oral and maxillofacial surgeon is needed to determine the most appropriate treatment approach."(Ghodasra, R., et al)

"In general, oral health-related quality of life of all subjects significantly improved after orthodontic treatment. Subjects with moderate malocclusion showed better improvement than severe malocclusion subjects."(Jamilian, A., et al)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for D8080 Braces, D8670 monthly visits, D8680 Retainer services is substantiated.