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Sumi Yokoyama

Appointment passed

Crown on #24, upper left first premolar · Crown appointment Tuesday Oct 6

  1. Needs the patient
  2. Paperwork
  3. Dentist review
  4. Ready to send
  5. With Sun Life
  6. Decision back You

Resubmit

You

The appointment has passed. Rebook the patient. Source

Sun Life denied it on Sep 17, 2026: Predetermination not approved. A current periapical radiograph of tooth 24 was not received. Resubmit with the radiograph.

Send a new request

Dr. Terry Ackerman signs it again, then you send it.

Ophi couldn't name Sun Life's reason on its own. Ophi can't reach Gemini: set GEMINI_API_KEY for the server.

Pick the reason yourself

Ask for reconsideration

By Nov 16, 2026, with new clinical information. One chance, and it's final. Done outside Ophi.

CDCP requirements9 of 13 documented
  • Satisfied
    Claim form (CDA/CLHIA standard, or computer-generated treatment form)
    Matrix Restorative services — Claim form: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Claim form: Yes Open the source document
  • Satisfied
    Treatment plan details — all relevant completed and pending treatment
    Matrix Restorative services — Tx plan: Yes (footnote 1) CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Tx plan: Yes (footnote 1) Treatment plan details indicating all relevant completed and pending treatment needs ... Does not need to be a stand-alone document labelled 'treatment plan' so long as the information is included in the documentation submitted. Open the source document via structured plan
  • Satisfied
    Dated periapical radiograph of the requested tooth, within 12 months
    Matrix Restorative services — PA+BW (R&L) <=12mo: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — PA+BW (R&L) <=12mo: Yes Also: CDCP Dental Benefits Guide (effective 2026-04-01), 6.1.2 Radiograph standards: Intraoral radiographs are considered 'current' for preauthorization purposes if dated within the last 12 months of the preauthorization submission. Open the source document
  • Satisfied
    Dated bitewing radiographs, right and left, within 12 months
    Matrix Restorative services — PA+BW (R&L) <=12mo: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — PA+BW (R&L) <=12mo: Yes Open the source document
  • Satisfied
    Dated complete periodontal chart, within 12 months
    Matrix Restorative services — Complete perio chart <=12mo: Yes, crowns only (footnote 7) CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Complete perio chart <=12mo: Yes, crowns only (footnote 7) If a complete perio chart is not available, a dated PSR for each sextant plus 6-site periodontal measurements for each tooth requested, within last 12 months, will be considered. Open the source document via complete perio chart
  • Satisfied
    Client is 18 or older
    Guide 6.3.5 Crowns CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns preauth, 18+ Open the source document
  • Satisfied
    Requested tooth is an incisor, canine, premolar, first or second molar (third molars by exception)
    Guide 6.3.5 Crowns — tooth eligibility CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — tooth eligibility incisors, canines, bicuspids, 1st and 2nd molars; third molars only where 1st and 2nd are missing and the 3rd is in occlusion with a prosthetic or natural molar Open the source document via standard tooth
  • Satisfied
    No CDCP crown on this tooth within the previous 96 months
    Grid Schedule B — 2.0 Restoration, crowns CDCP Dental Benefit Grid — Ontario, General Practitioners and Specialists, 2026 Schedule B — 2.0 Restoration, crowns 1/96mo/tooth Open the source document
  • Satisfied
    Fewer than 4 crowns for this client within the previous 120 months
    Grid Schedule B — 2.0 Restoration, crowns CDCP Dental Benefit Grid — Ontario, General Practitioners and Specialists, 2026 Schedule B — 2.0 Restoration, crowns 4/120mo/client Open the source document
  • Awaiting dentist
    All basic treatment for active caries and periodontal disease completed
    Guide 6.3.5 Crowns CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns All basic treatment addressing any existing active biological disease (caries and periodontal) must be completed before submitting requests for crowns. Open the source document
    Awaiting the treating dentist's confirmation of 1 criterion.
  • Awaiting dentist
    Restorability criteria confirmed by the treating dentist
    Guide 6.3.5 Crowns — restorability CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — restorability Open the source document
    Awaiting the treating dentist's confirmation of 7 criteria.
  • Awaiting dentist
    Tooth meets the "extensively restored" definition
    Guide 6.3.5 Crowns — extensively restored CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — extensively restored Open the source document
    Awaiting the treating dentist's confirmation of 1 criterion.
  • Awaiting dentist
    Endodontically treated tooth has healed
    Guide 6.3.5 Crowns CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns An endodontically treated tooth must have healed before requesting a crown. Open the source document
    Awaiting the treating dentist's confirmation of 1 criterion.

Not applicable here: Laboratory fee codes are valid for the 2026 date of service.

What Ophi read in the chart5 radiographs, 3 perio records, 14 notes

Radiographs

PA
Dec 13, 2004
PA
Jun 20, 2007
PA #24
Aug 20, 2026, current until Aug 20, 2027
BW right #14, #15, #16, #17, #44, #45, #46, #47
Aug 20, 2026, current until Aug 20, 2027
BW left #24, #25, #26, #27, #34, #35, #36, #37
Aug 20, 2026, current until Aug 20, 2027
A bitewing does not show the root tip.

Periodontal charting

Perio chart Dec 13, 2004 uncertified draft
6 sites per tooth, 28 of 28 teeth
#24 323434
Perio chart Dec 14, 2005 uncertified draft
6 sites per tooth, 28 of 28 teeth
#24 323333
Perio chart Aug 20, 2026
6 sites per tooth, 28 of 28 teeth, current until Aug 20, 2027
#24 323323

Clinical notes

Dec 13, 2004, Dr. Terry Ackerman

[MH]New Medical History completed: EXTRAORAL EXAM: WNL: INTRAORAL EXAM: WNL: (sub)generalized moderate: (supra)- moderate lingual mandible and facial maxilla: Discussed w/p OH issues,risk of disease progression/tooth mobility/loss

Dec 13, 2004, Dr. Terry Ackerman

Oral B brush: Ultra floss: sulcabrush

Dec 13, 2004, Dr. Terry Ackerman

Fillings are breaking down. Watch till next rc

Jun 8, 2005, Dr. Terry Ackerman

Ultracaine 2% 1:50,0003 carp: Mandibular Block & Long Buccal: [COMP]Placed RD: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]Filtex SupremeA1: MaterialEsthetX A1

Dec 14, 2005, Dr. Kim Black

RECALL: OH Poor; Abundant calc; Abundant Calc; mod/severe generalized gingivitis: Discussed w/p OH issues,risk of disease progression/tooth mobility/loss : Scaled all quads, prophy,floss: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after

Dec 14, 2005, Dr. Kim Black

RECALL

Dec 14, 2005, Dr. Kim Black

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: OH Fair; Mod.calc. Mod.plaque, Mod.generalized gingivitis: Scaled all quads, prophy,floss: Scaled: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after

Jan 19, 2006, Marj Brooks

Lidocaine 2% 1:100,000 1 carp: Infiltrated: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]3M Z100

Jan 19, 2006, Marj Brooks

Lidocaine 2% 1:100,0001:: Infiltrated: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondBisco 1step: [COMP]Filtex SupremeA11 carp

Dec 14, 2006, Marj Brooks

Gingivae pink looking much healthier than when we first saw Sumi: slight bleedinggeneralized: moderate gingival thirds: no stain: Oral B brush: Ultra floss

Jun 20, 2007, Marj Brooks

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: OH Fair; Mod.calc. Mod.plaque, Mod.generalized gingivitis: Scaled all quads, prophy,floss: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after

Dec 17, 2007, Dr. Terry Ackerman

SeptanestSP4%2carps: Infiltrated: placed rubber dam: created access: shaped with files: Peso Burssize 2: Rinsed with Sodium Hypochlorite 50%: Canals: B25;22mm: M25;23mm: GP0420: Backfill23gauge: composite

Dec 17, 2007, Dr. Terry Ackerman

[PST]sized to parapostred: [PST]cemented withParapost cem.

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 24: large failing restoration with a fractured cusp and recurrent decay under the margin. Vital, no periapical pathology on today's PA. Remaining restorations sound. Plan: PFM crown 24.

Procedure history

CodeToothDate
02111#24Aug 20, 2026
02144—Aug 20, 2026
33121#24Dec 17, 2007
25731#24Dec 17, 2007
01202—Jun 20, 2007
11112—Jun 20, 2007
43422—Jun 20, 2007
11101—Jun 20, 2007
12101—Jun 20, 2007
02111—Jun 20, 2007
33121#24Jun 20, 2007
25731#24Jun 20, 2007
27211#24Jun 20, 2007
11113—Dec 14, 2006
43423—Dec 14, 2006
23111#11Jun 19, 2006
23111#21Jun 19, 2006
01202—Dec 14, 2005
11113—Dec 14, 2005
11117—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
23111#11Dec 14, 2005
23111#21Dec 14, 2005
23323#36Jun 8, 2005
23313#35Jun 8, 2005
23312#34Jun 8, 2005
02119—Dec 13, 2004
01103—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11101—Dec 13, 2004
12101—Dec 13, 2004
23323#36Dec 13, 2004
23313#35Dec 13, 2004
23312#34Dec 13, 2004