CDC Treatment Planning & Protocols 3

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Control of active infection and elimination of disease

Answer

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?

Accepted Answer

Deny the bridge benefit due to the missing tooth clause

Answer

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:

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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

(CDC) Certified Dental Coder Practice Test

(CDC) Certified Dental Coder Practice Test

CDC Treatment Planning & Protocols 3