Treating Medicare Advantage and D-SNP program dentists who would like to discuss the clinical rationale (e.g., clinical criteria and issues of medical necessity, appropriateness of care, or contractual clinical limitations) for an initial adverse determination of a dental procedure may request a discussion with a professional peer reviewer prior to final adjudication.
This process cannot be used to request a reconsideration of the original determination and is not considered an appeal.
Any request to change an initial adverse decision must be handled through the defined reconsideration process—not through a peer-to-peer discussion. For more information on how to request a clinical conversation, please select the “Peer-to-Peer” Discussion tab for more details