CDC Treatment Planning & Protocols 3 — Questions and Answers
Question 1: 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?
- Approve — anterior teeth always warrant crowns for aesthetics
- Deny or request additional documentation — crown criteria do not appear to be met (Correct answer)
- Approve with a downgrade to a PFM crown
- Defer to the treating dentist without clinical review
Correct 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.
Question 2: Which of the following scenarios best represents a 'phase I' treatment priority in a comprehensive dental treatment plan?
- Elective orthodontic treatment
- Control of active infection and elimination of disease (Correct answer)
- Cosmetic veneers on anterior teeth
- Implant placement for missing posterior teeth
Correct 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.
Question 3: 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?
- Approve the bridge since the member has current coverage
- Deny the bridge benefit due to the missing tooth clause (Correct answer)
- Approve partial benefit based on years of coverage
- Request records from the previous insurer before deciding
Correct 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.
Question 4: 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:
- Immediately terminate the provider from the network
- Initiate a focused clinical review or audit of the provider's records (Correct answer)
- Approve all claims to avoid provider complaints
- Report directly to law enforcement
Correct 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.
Question 5: A treatment plan includes a sinus lift (elevation) prior to implant placement. Under most dental benefit plans, how is a sinus lift typically classified?
- A routine pre-prosthetic procedure covered under restorative benefits
- A surgical procedure that may fall under oral surgery benefits and require separate review (Correct answer)
- A cosmetic procedure excluded from dental benefits
- A periodontal procedure covered under preventive benefits
Correct 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.
Question 6: 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:
- Approve the bridge since the patient has already lost a tooth
- Deny or defer approval until periodontal disease is stabilized (Correct answer)
- Approve only if the abutment teeth are sound
- Approve with a note to the provider recommending periodontal treatment
Correct 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.
Question 7: Which ADA procedure code best describes a complete denture for the maxillary arch?
- D5110 (Correct answer)
- D5120
- D5130
- D5140
Correct answer: D5110
D5110 is the ADA code for a complete maxillary denture.
CDC Treatment Planning & Protocols 3
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?