Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment D8080 (braces) and D8670 (monthly visit x (times) 12).
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
The denial is upheld.

Medicine targets health in issues of saving life and improving quality of life. Most orthodontic procedures deal with the latter goal. Medical necessity is presented within the scope of pediatric orthodontics, stratified in medically guided treatment, when orthodontic procedures contribute to the correction of a systemic problem, whether or not associated with a local orofacial problem (respiration and sleep disorders, emotional problems, and hospital calls); and orofacial-guided treatment, when addressing growth matters, craniofacial anomalies, and orofacial functions (mastication, understandable speech, and temporomandibular pain). 

If teeth do not occlude properly masticatory function can be impaired, with patients reporting difficulty in biting through food or poor chewing ability, which in turn can lead to social embarrassment. Damage to the long-term health of the teeth and periodontium can include risk of trauma to the maxillary incisors where the overjet is increased. It is well known that the more prominent the upper incisors the more prone they are to trauma.  Studies have shown that overjets over 3 millimeters (mm) have twice the risk of trauma to anterior teeth compared with those less than 3 mm. 

Traumatic deep overbite or anterior crossbite with mandibular displacement can be associated with periodontal breakdown indicating a need for treatment and impacted teeth can cause damage to the root surface of adjacent teeth causing root resorption. Supernumerary teeth may also cause damage to adjacent teeth or prevent the normal eruption of a permanent tooth.

The need for orthodontic treatment depends on the impact of the malocclusion and whether treatment is likely to provide a demonstrable benefit to the patient. To determine whether orthodontic treatment is likely to carry a dental health benefit, it Is necessary to consider first whether the malocclusion is likely to cause problems to dental health and secondly, whether orthodontic treatment is likely to address the problem. There are specific occlusal anomalies were evidence suggests orthodontic treatment may provide a dental health benefit. These are:

1)	Crowding causing teeth pushed out of the bony trough, resulting in recession
2)	Periodontal damage related to traumatic overbites
3)	Anterior crossbites with evidence of compromised buccal periodontal support on affected lower incisors
4)	Increased overjet with increased risk of dental trauma
5)	Unerupted impacted teeth with risk of pathology
6)	Crossbites associated with mandibular displacement

Patients with significant inter-arch discrepancy including anterior open bite and markedly increased or reverse over jet often report difficulty with eating.

Indices have been developed where the demand is high to manage demand and support prioritization. Examples of such indices are the Index of Orthodontic Treatment Need (IOTN) and the Handicapping Labio-Lingual Deviation Index Report (HLD). The IOTN classifies the need for treatment as a very great need, great need, moderate need, mild need or no need. 

The photographs and radiograph and letter from the provider show that there is mild maxillary spacing, minor mandibular crowding with no excessive overjet and several teeth with a mild crossbite. There is no open bite. Regarding the IOTN, the patient would be classified as having a mild need. Based on the available information, orthodontics would straighten the teeth and there is a mild need for treatment. There are no functional problems documented and there is no demonstrable pathology, therefore, it cannot be stated that the treatment is medically necessary.

The health plan acted reasonably with sound medical judgement in the best interest of the patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is upheld. Medical necessity is not substantiated.