CDC Treatment Planning & Protocols 2 — Questions and Answers
Question 1: A dental consultant is reviewing a claim for a patient who received a full-mouth series of radiographs 10 months ago. The provider now requests bitewing radiographs. What is the most appropriate determination?
- Deny — full-mouth series was too recent for any additional radiographs
- Approve — bitewings serve a different diagnostic purpose than a full-mouth series (Correct answer)
- Approve only if the patient has active periodontal disease
- Pend for additional clinical documentation before deciding
Correct answer: Approve — bitewings serve a different diagnostic purpose than a full-mouth series
Bitewing radiographs serve a distinct diagnostic purpose (interproximal caries detection) and are not duplicative of a full-mouth series.
Question 2: Under standard dental benefit protocols, which factor most commonly justifies deviation from a 'least costly alternative' (LCA) determination?
- Patient preference for a more aesthetic restoration
- Documented clinical contraindication to the less costly treatment (Correct answer)
- Provider's usual and customary fee exceeding the plan maximum
- Geographic location of the treating dentist
Correct answer: Documented clinical contraindication to the less costly treatment
A documented clinical contraindication is the primary basis for approving a more costly alternative when an LCA determination has been made.
Question 3: A treatment plan includes extraction of tooth #14 and a three-unit bridge replacing #13-#15. The patient's plan covers single-tooth implants as an alternative. Which protocol should the consultant apply?
- Approve the bridge at full benefit since it was the provider's choice
- Apply LCA and pay bridge benefit only up to the cost of the implant alternative (Correct answer)
- Deny the bridge entirely since implants are available
- Approve the implant and deny the bridge
Correct answer: Apply LCA and pay bridge benefit only up to the cost of the implant alternative
When a plan covers multiple treatment alternatives, the LCA provision limits reimbursement to the benefit of the less costly covered option.
Question 4: Which of the following best describes the appropriate review standard for a proposed treatment plan involving full-mouth rehabilitation?
- Administrative review only, since complex cases are always approved
- Clinical review using evidence-based criteria and full documentation including radiographs, periodontal charting, and study models (Correct answer)
- Automatic denial due to high cost
- Peer review by a specialist in oral surgery only
Correct answer: Clinical review using evidence-based criteria and full documentation including radiographs, periodontal charting, and study models
Full-mouth rehabilitation requires comprehensive clinical review with supporting documentation to establish medical necessity and appropriateness.
Question 5: A patient has a treatment plan for four quadrants of scaling and root planing (SRP) on the same date of service. The plan typically limits SRP to two quadrants per visit. What is the consultant's best course of action?
- Deny all four quadrants as non-covered
- Approve all four quadrants without review
- Review clinical documentation to determine if the full-mouth protocol is clinically justified (Correct answer)
- Approve only two quadrants and deny the remaining two
Correct answer: Review clinical documentation to determine if the full-mouth protocol is clinically justified
Full-mouth SRP in one visit (FMSD protocol) can be clinically justified; the consultant should review periodontal records before limiting benefits.
Question 6: When evaluating a treatment plan, which of the following is considered the most critical element of the informed consent process from a dental consultant's review perspective?
- The patient's signature on a financial agreement
- Documentation that the patient received and understood the risks, benefits, and alternatives to proposed treatment (Correct answer)
- The length of the appointment scheduled for the procedure
- Proof that the patient has dental insurance coverage
Correct answer: Documentation that the patient received and understood the risks, benefits, and alternatives to proposed treatment
Informed consent requires documented evidence that the patient understood the risks, benefits, and alternatives, not merely a signature on a financial form.
Question 7: A dental consultant reviews a claim for a posterior composite on tooth #30. The patient's plan covers posterior composites but at the amalgam benefit. The provider billed the composite fee. How should the benefit be calculated?
- Pay the full composite fee as billed
- Deny the claim since composites are not covered posteriorly
- Pay at the amalgam (alternative benefit) fee level (Correct answer)
- Request a second opinion before adjudicating
Correct answer: Pay at the amalgam (alternative benefit) fee level
Alternative benefit provisions pay at the cost of the covered alternative (amalgam) when the patient selects a more expensive option such as a posterior composite.
CDC Treatment Planning & Protocols 2
A dental consultant is reviewing a claim for a patient who received a full-mouth series of radiographs 10 months ago.
The provider now requests bitewing radiographs.
What is the most appropriate determination?