Malocclusion: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for comprehensive orthodontic treatment of adolescent dentition. The enrollee has bilateral severely impacted maxillary cuspids, transversely constricted dental arches, a 100% deep and impinging overbite, and ankyloglossia with resultant tongue-thrust habit. The provider has recommended orthodontic treatment to provide the best chance of developing a healthy, functional occlusion; including attempting to successfully bring his ectopically impacted cuspids into proper occlusion. The provider indicates there is a possibility of root damage to the adjacent teeth due to the impacted cuspids, and a possibility the impacted cuspids could become ankylosed. Upon review of the record, it is evident the enrollee exhibits a significant malocclusion.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for orthognathic surgery. In this case, the records establish that the patient has maxillary hypoplasia and mandibular hyperplasia (prognathism), resulting in malocclusion and facial asymmetry. The patient reports difficulty biting and chewing, an uncomfortable bite, difficulty smiling, and issues with tongue positioning. Surgical correction is required to address the underlying skeletal deformity.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for genioplasty surgery. Genioplasty is the gold standard technique to modify the natural chin anatomy based on a mandible inferior border osteotomy enabling three-dimensional repositioning of the chin. In this case, the patient has a history of maxillofacial deformity with malocclusion and temporomandibular joint (TMJ) pain. The records submitted for review indicate that the patient was experiencing malocclusion due to congenital hypoplasia of the maxilla with retrognathia and hypoplasia of the mandible with retrognathia, which caused difficulty in masticating and TMJ pain. The patient underwent orthognathic surgery for malocclusion and TMJ dysfunction, specifically, LeFort 1 osteotomy with advancement and bilateral sagittal split with mandibular advancement.

The patient is a four-year-old male with a history of a cleft lip and palate, which was treated by a cranial facial center. He has undergone reconstructive cleft lip/palate surgery. The records provided indicate the patient has an unrepaired cleft alveolar ridge, communication impairment, and otitis media with effusion. The patient has been seen at the cranial facial center five times and the cranial facial team performed all of the reconstruction surgery needed to date. The Health Plan indicates it is not medically necessary for the patient to continue to receive services from the same cranial facial team.Review of the submitted clinical records indicates the patient has a cleft lip/palate congenital deformity. Part of the deformity is Eustachian tube dysfunction with resultant middle ear effusions and resultant otitis media.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for malocclusion was denied, the published record says the denial is worth fighting.