Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
 
Treatment: Orthodontic Treatment

The insurer denied the Orthodontic Treatment. The denial was reversed.    

This is a female patient with malocclusion who is seeking orthodontic therapy.

The patient has skeletal class 1, normal vertical growth pattern, permanent dentition, class ll canines, mild maxillary spacing, mild mandibular spacing, moderate excessive overjet, due to the addition of the qualifying diagnosis, deep impinging overbite with severe soft tissue damage (an auto-qualifying condition) the patient qualifies for treatment.

Per Penelli Valarelli, F., et al. (2017), "Deep overbite correction is one of the primary goals of orthodontic treatment.[14] This malocclusion is characterized by the vertical overbite in the anterior region,[15] and it is also recurrent in adult patients, either by their growth pattern or by some dental-related factors, such as loss of posterior teeth, that can be one of the main etiological factors of this malocclusion. To treat deep overbite, the following orthodontics mechanics can be performed: mandibular and maxillary posterior teeth extrusion, mandibular and maxillary anterior teeth intrusion, maxillary clockwise rotation, and curve of Spee flattening. It is important to highlight that at this life period (adult age) the orthodontic treatment stability has a high potential to relapse, due to less ability to adapt perioral muscles and temporomandibular joint to the new dental positions.[16,17]"

Millett, D. T., et al. (2018) states, "A Class II division 2 malocclusion is characterized by upper front teeth that are retroclined (tilted toward the roof of the mouth) and an increased overbite (deep overbite), which can cause oral problems and may affect appearance. This problem can be corrected by the use of special dental braces (functional appliances) that move the upper front teeth forward and change the growth of the upper or lower jaws, or both. Most types of functional appliances are removable and this treatment approach does not usually require extraction of any permanent teeth. Additional treatment with fixed braces may be necessary to ensure the best result. An alternative approach is to provide space for the correction of the front teeth by moving the molar teeth backwards. This is done by applying a force to the teeth from the back of the head using a head brace (headgear) and transmitting this force to part of a fixed or removable dental brace that is attached to the back teeth. The treatment may be carried out with or without extraction of permanent teeth. If headgear use is not feasible, the back teeth may be held in place by bands connected to a fixed bar placed across the roof of the mouth or in contact with the front of the roof of the mouth. This treatment usually requires two permanent teeth to be taken out from the middle of the upper arch (one on each side)."                                                         
 
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient has met the HLD criteria, in that there is documentation of an auto qualifier.

Based on the above, the medical necessity for the comprehensive orthodontic treatment (D8080) is substantiated.  The insurer's denial is reversed.