Treatment Planning & Protocols Flashcards

A consultant receives a pre-authorization request for a crown on tooth #8, which has a 3mm composite restoration and no evidence of structural compromise on radiographs. What is the most appropriate response?

Answer: Deny or request additional documentation — crown criteria do not appear to be met

Crown coverage criteria typically require significant structural loss or other clinical indicators; a small composite restoration alone does not meet most plan thresholds.

Which of the following scenarios best represents a 'phase I' treatment priority in a comprehensive dental treatment plan?

Answer: Control of active infection and elimination of disease

Phase I treatment focuses on disease control — managing infections, caries, and periodontal disease before restorative or elective care.

A dental plan uses a 'missing tooth clause.' A member requests a bridge to replace tooth #19, which was extracted before the member's enrollment. How should the consultant handle this?

Answer: Deny the bridge benefit due to the missing tooth clause

The missing tooth clause excludes benefits for replacement of teeth lost prior to effective coverage date.

When a dental consultant identifies a pattern of a provider submitting treatment plans for crowns on teeth with minimal restorations across multiple patients, the most appropriate initial action is to:

Answer: Initiate a focused clinical review or audit of the provider's records

A utilization pattern suggesting over-treatment warrants a focused clinical audit before any adverse action against the provider.

A treatment plan includes a sinus lift (elevation) prior to implant placement. Under most dental benefit plans, how is a sinus lift typically classified?

Answer: A surgical procedure that may fall under oral surgery benefits and require separate review

Sinus lifts are surgical procedures adjunctive to implant placement and typically reviewed under oral surgery benefit provisions.

A consultant must determine if a proposed fixed partial denture (bridge) is appropriate when the patient has active, uncontrolled periodontal disease. The correct clinical position is:

Answer: Deny or defer approval until periodontal disease is stabilized

Placing a bridge in an uncontrolled periodontal environment risks failure; definitive prosthetic treatment should follow disease stabilization.

Which ADA procedure code best describes a complete denture for the maxillary arch?

Answer: D5110

D5110 is the ADA code for a complete maxillary denture.