Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 

Treatment: Braces (comprehensive orthodontic treatment). 

The insurer denied coverage for Braces (comprehensive orthodontic treatment). 

The denial is upheld. 

The medical records provided for review show that the patient is being seen by orthodontist to treat her malocclusion. The patient has a class one (1) malocclusion with mild maxillary and mandibular crowing noted, as well as an anterior crossbite. The patient's Handicapping Labio-Lingual Deviations (HLD) score is documented to be six (6) due to their overjet and overbite according to the insurer. 

The patient has a documented handicapping labio-lingual deviation (HLD) score of six (6) per the insurer, which is below the required number for approval of coverage. The score includes an overjet of two (milliliters) mm and an overbite of two (2) mm. The patient does, however, have some crowding in each arch. The medical records do not show that the patient is having any mechanical issues caused by the teeth nor are the teeth, in their present condition, causing any physical or mental deficits. As such, even with the crowding, the patient does not meet criteria for approval and the braces are not 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%. 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, 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 (comprehensive orthodontic treatment) is not substantiated.