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

This is a male patient with a Class I bite and severe crowding in both the maxillary and mandibular arches. Tooth 31 is impacted. The patient is treatment planned for 24-36 months of orthodontics with extraction of teeth 5 and 29 but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces.

Impacted teeth can lead to bone defects of the adjacent erupted teeth. (1) 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.
The patient has an impacted mandibular right second molar. This tooth should have erupted. (2) Side effects of impacted mandibular second molars include a significant increase in periodontal defects distal to the erupted first molars (3) due to the inadequate development of bone in that region as a result of the impacted tooth. No treatment will put the mandibular right first molar (tooth 30) at risk. Therefore, orthodontic treatment is medically necessary.