Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion, maxillary vertical deficiency

Treatment: Full set of braces

The insurer denied coverage for a full set of braces. The denial is reversed. 

This patient is a male child with a history of Class III malocclusion, maxillary vertical deficiency, mandibular asymmetry, severe impactions of multiple permanent teeth, and a posterior open bite. The patient has an impacted upper right permanent canine and an impacted permanent lower right second molar. Per the oral/maxillofacial surgeon the patient will eventually need jaw surgery to correct skeletal discrepancies; the surgery should include a maxillary Lefort osteotomy. The first phase should be addressing tooth spacing issues and impacted teeth. Jaw surgery should be done at the age of 17 or 18 and the patient should receive a full set of braces prior to surgery.

Abdolreza, J., et al., (2015), stated: "People who can potentially benefit from orthognathic surgery include those with jaws that are positioned incorrectly. Orthognathic surgery is also the treatment of choice in patients who have not had the benefit of dentofacial orthopedics for growth guidance, or in cases where the deformity is so severe that orthodontics alone is not enough to correct it. Achieving successful treatment outcomes in these patients requires implementing an effective treatment plan. It should be considered that treatment planning is one of the most important stages because once the treatment is started it is hardly possible to reverse or suspend it. At this stage, the patient should be verified to have no potential of growth. If the patient is still growing he or she should be examined annually until growth is complete, 188."

American Academy of Pediatric Dentistry, (2019), guidelines also address this patient's Class III condition and support the doctor's recommendation as follows: "General considerations and principles of management: Class III malocclusion (mesio-occlusion) involves a mesial relationship of the mandible to the maxilla or mandibular teeth to maxillary teeth. This relationship may result from dental factors (malposition of the teeth in the arches), skeletal factors (asymmetry, mandibular prognathism, and/or maxillary retrognathism), anterior functional shift of the mandible, or a combination of these factors."

Treatment of Class III malocclusions is indicated to provide psychosocial benefits for the child patient by reducing or eliminating facial disfigurement and to reduce the severity of malocclusion by promoting compensating growth, 192. Interceptive Class III treatment has been proposed for years and has been advocated as a necessary tool in contemporary orthodontics, with initiation in the primary-early mixed dentition recommended, 193-202. Factors to consider when planning orthodontic intervention for Class III malocclusion are: (1) facial growth pattern; (2) amount of AP discrepancy; (3) patient age; (4) projected patient compliance; and (5) space analysis.


A full set of braces is considered medically necessary for this patient because the current position of the teeth is only correctible with orthodontic and/or surgical intervention as stated in the several letters of medical necessity submitted by the patient's orthodontist that are attached to this claim. This recommendation is supported by Abdolreza et al (2015) which have an entire textbook chapter dedicated to this subject.  Therefore, the full set of braces in preparation for maxillofacial surgery is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.                                                        

Based on the above, the medical necessity for a full set of braces is substantiated.  The insurer's denial is reversed.