Treatment Planning & Protocols Flashcards
7 cards from real CDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Treatment Planning & Protocols flashcards as text
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?
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.
Under standard dental benefit protocols, which factor most commonly justifies deviation from a 'least costly alternative' (LCA) determination?
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.
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?
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.
Which of the following best describes the appropriate review standard for a proposed treatment plan involving full-mouth rehabilitation?
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.
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?
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.
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?
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.
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?
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.