Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 Comprehensive Orthodontic treatment of the Adolescent Dentition

The insurer denied coverage for D8080 Comprehensive Orthodontic treatment of the Adolescent Dentition

The denial is upheld
 

The documents provided for review indicate that the patient has deep impinging overbite causing severe soft tissue damage; however, severe soft tissue damage is not observed in the attached records. There is no letter of medical necessity attached, which describes a physically handicapping malocclusion. There is no mention of any congenital syndrome(s) affecting growth and development of the head, neck, teeth, or associated structures.

The patient's Handicapping Labio-Lingual Deviation (HLD) score is reported as a 14 and a score of at least 26 is required for the patient's orthodontic care and braces to be a covered expense.

There was no medical or dental history attached; however, the clinical photographs and panoramic/cephalometric radiographic images were reviewed.

D8080 Comprehensive Orthodontic treatment of the Adolescent Dentition is not considered medically necessary for this patient as severe soft tissue damage is not observed on the attached documentation. 

"There are several methods to treat malocclusion. Palatal expanders are traditionally used before braces treatment to treat a narrow palate, crowding, or crossbite. Rapid palatal expansion (RPE) works by placing a force on the two maxillary bones to split the mid-palatal suture. Palatal expanders are most useful during adolescence, as the maxillary bones become fused during puberty. The expander contains a screw turned daily or as directed by the patient's orthodontist. Every turn places pressure on the maxillary bone, allowing for less than 1 mm of expansion." (Ghodasra, R., & Brizuela, M. 2023).

The American Association of Orthodontists (AAO) has defined medically necessary orthodontic care as "the treatment of a malocclusion (including craniofacial abnormalities/anomalies) that compromises the patient's physical, emotional or dental health."...

Malocclusion refers to an improper alignment of the upper and lower teeth. Data from the 2007 to 2009 Canadian Health Measures Survey suggested that the prevalence of malocclusion and past orthodontic treatment among Canadian adults aged 20 to 59 years was 25% and 20%, respectively. According to the 2009 to 2010 First Nations Oral Health Survey, the prevalence of malocclusion among First Nations aged 12 years and over was 30.3%, and 98.6% among them received no orthodontic treatment.

There are several causes for malocclusion, including hereditary, tooth overcrowding, lost teeth, abnormal bite patterns, ill-fitting dental fillings, cleft lip and palate, tumor of mouth and jaw, and impacted teeth. Common conditions of malocclusion are upper protrusion (i.e., over jet), spacing or crowding problems, misplaced midline, open bite, overbite, cross bite, underbite, rotation and transposition. There are three major classes of malocclusion: Class 1 (i.e., upper teeth overlap the lower teeth, most common); Class 2 (i.e., severe overbite); Class 3 (i.e., severe underbite).1" (Tran, K. & Picheca, L. 2017).

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 D8080 Comprehensive Orthodontic treatment of the Adolescent Dentition services is not substantiated.