Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces

The insurer denied coverage for braces

The denial is upheld.


The medical records indicate that patient has an overjet, overbite and anterior mandibular crowding. There is no mention of any congenital syndrome(s) affecting growth and development of the head, neck, teeth, or associated structures. The photographs, attached, support the provider's claim that the patient's teeth are not properly aligned. No medical or dental history is attached nor is there a letter of medical necessity which describes a physically handicapping malocclusion.

The patient does not exhibit a severe, handicapping malocclusion, and the Handicapping Labio-Lingual Deviations (HLD) score is too low (13). There is no letter of medical necessity, from the patient's health care team, indicating that they must have braces to treat, prevent, or modify a serious pre-existing condition. 

While the patient may benefit from orthodontic treatment, the request for braces has not been shown to be medically necessary for this patient. 

"Dental crowding is a discrepancy between jaw and teeth size, which leads to misalignment. It is seen when the size of the teeth is more compared to that of the jaws. According to a study conducted by Ahamed et al. in Tamil Nadu, the increase in consumption of processed food has increased the prevalence of dental crowding, which has increased to almost 60% (percent). The most common etiology of crowding is proximal caries in the primary dentition, which leads to mesial shifting of the posterior teeth, causing a decrease in jaw size. Other causes of crowding include genetics, deleterious habits, poor dental hygiene, and cleft lip and palate. Crowding is classified into three groups, such as mild, moderate, and severe, according to the amount of overlap present. Treatment includes creating space using extraction, interproximal stripping, expansion, distalization of molars, derotation, and uprighting teeth. This decision about creating space is made according to the severity of crowding. Severe crowding calls for the extraction of one or more teeth; moderate crowding is treated using interproximal stripping or extraction of a single incisor, whereas mild crowding is treated using stripping." (Nerurkar, S., et al., 2023).

"In dental crowding therapy, it is important to quantify the lack of space in the dental arch in order to choose an appropriate orthodontic therapy. A correct diagnosis is obtained through clinical examination, radiographic image (X-rays), cephalometric analysis and study models. Cone-beam computed tomography (CBCT) provides additional support for the diagnosis. The mandible is considered the guiding arch in orthodontic therapy, as it is not very modifiable. The correction of severe mandibular crowding in mixed dentition can be achieved by extraction, distalization and surgical and non-surgical expansion of the mandible. The degree of crowding is influenced by the direction of mandibular development, early loss of primary molars, arch size, buccal musculature and the inclination of the incisors and molars. In mixed dentition, there are various ways to recover space that can be combined: maintaining the leeway space, lengthening the arch perimeter, resorting to extractions, stripping, etc. Decisions on crowding management must be made in the context of an overall assessment of the malocclusion to be treated." (Patano, A., et al., 2023).

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