CDC Treatment Planning & Protocols 2

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?

Accepted Answer

Approve — bitewings serve a different diagnostic purpose than a full-mouth series

Answer

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?

Accepted Answer

Documented clinical contraindication to the less costly treatment

Answer

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?

Accepted Answer

Apply LCA and pay bridge benefit only up to the cost of the implant alternative

Answer

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?

Accepted Answer

Clinical review using evidence-based criteria and full documentation including radiographs, periodontal charting, and study models

Answer

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?

Accepted Answer

Review clinical documentation to determine if the full-mouth protocol is clinically justified

Answer

Full-mouth SRP in one visit (FMSD protocol) can be clinically justified; the consultant should review periodontal records before limiting benefits.

(CDC) Certified Dental Coder Practice Test

(CDC) Certified Dental Coder Practice Test

CDC Treatment Planning & Protocols 2