Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental problem (class two malocclusion). 
Treatment:  Orthodontic braces and treatment visits.

The insurer denied coverage for orthodontic braces and treatment visits.  The denial is upheld. 

This patient is a female child who is under the care of an orthodontist.  The patient appears to have a class two malocclusion.  

"Maxillary incisors retroclination is one of the most important Class II division 2 malocclusion feature.  In this malocclusion, mandibular incisors generally are also retruded and subsequently crowded as well.  In the maxillary incisors palatal site, it is common to note that the gum in this area may be subject to trauma due the deep overbite and well-pronounced curve of Spee" (Valarelli et al).

"Orthodontics is concerned with growth of the jaws and face, development of the teeth, and the way teeth and jaws bite together.  Ideally, the lower front teeth bite in the middle of the back surface of the upper front teeth.  When the lower front teeth bite further behind the upper front teeth than ideal, this is known as a Class II malocclusion.  A Class II division 2 malocclusion is characterised by upper front teeth that are retroclined (tilted toward the roof of the mouth) and an increased overbite (vertical overlap of the front teeth), 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" (Millett et al).

"Malocclusion is the false arrangement of teeth in three planes of space.  Angle classified malocclusion in the sagittal plane based on the dental relationship and ignoring the skeletal relation.  The disto-occlusion is categorized into division 1 and division 2 based on the spatial orientation of upper anterior teeth.  Apart from these basic features, there were no characteristic features pertaining to Class II div [division] 2 in the literature.  The Class II div 2 malocclusion is rare and procuring the study sample is always a difficult task.  Even though Angle gave the classification of malocclusion in 1890s, there is still lack of clarity regarding the classical features of Class II div 2 malocclusion" (Dodda et al).                                                         

The quality of the records provided for review was poor.  The photographs were almost illegible, and there were no orthodontist records provided, including Handicapping Labio-Lingual Deviation (HLD) scoring.  The provider's office was contacted on two occasions to request clearer copies of the photos and X-rays.  To date, these were not provided.
 
For orthodontic services to be considered medically necessary, there needs to be either an automatic qualifying condition such as cleft palate or cranio-facial anomaly, trauma, speech issue, deep impinging overbite with tissue damage, anterior crossbite of maxillary incisor/canine tooth/teeth with gingival recession, overjet of 9mm [millimeters] with incompetent lips, negative overjet 3.5mm or greater with masticatory/speech difficulties or impacted incisors or canines that will not erupt into arches without orthodontic treatment.

At this time, based on the records provided, it appears the plan acted reasonably and with sound judgement.  The insurer's HLD indicated no automatic qualifiers with an overall score of 12 - 5 points for overjet (5mm), 5 points for overbite (5mm) and 2 points for labio-lingual spread (2mm).

Due to the poor quality radiographs and photographs followed by no clinical notes, the medical necessity of orthodontic braces cannot be substantiated.  

The carrier's denial of coverage for orthodontic braces and treatment visits is upheld.  The medical necessity is not substantiated.