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Mathew Cherski

Sent 23 days ago

Crown on #26, upper left first molar · Crown appointment Wednesday Oct 14

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

Record Sun Life's decision

You

Past Sun Life's usual 7 days. Source

Sun Life will answer this one by mail. When the letter comes, upload it.

ABELDent: Pred. Sent, expect paper response · Sun Life's reference SL260915000160

Sun Life's decision
CDCP requirements8 of 12 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
  • Awaiting confirmation
    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 plan in note
    tx plan details proposed from free text (heuristic); a human must confirm before this counts
  • 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.

Not applicable here: Endodontically treated tooth has healed; Laboratory fee codes are valid for the 2026 date of service.

What Ophi read in the chart5 radiographs, 4 perio records, 14 notes

Radiographs

PA
Dec 13, 2004
PA
Dec 17, 2007
PA #26
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, 27 of 28 teeth
#26 525525
Perio chart Dec 14, 2005 uncertified draft
6 sites per tooth, 27 of 28 teeth
#26 434434
Perio chart Dec 17, 2007 uncertified draft
6 sites per tooth, 27 of 28 teeth
#26 434434
Perio chart Aug 20, 2026
6 sites per tooth, 28 of 28 teeth, current until Aug 20, 2027
#26 323323

Clinical notes

Dec 13, 2004, Dr. Terry Ackerman

[MH]New Medical History completed: moderate bleeding with probe and scale: root surfaces generally rough: sc3u: Explained Periodontal Disease to patient and discussed treatment.: (sub)-abundant lingual mandible and facial maxilla: (supra)- moderate lingual mandible and facial maxilla: Oral B brush: Ultra floss

Dec 13, 2004, Dr. Terry Ackerman

OId Ag's 26 &27have considerable overhangs, should be replaced

Jun 8, 2005, Marj Brooks

moderate bleeding with probe and scale: root surfaces generally rough: sc2u: Explained Periodontal Disease to patient and discussed treatment.

Jun 8, 2005, Dr. Terry Ackerman

[COMP]Placed RD: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]Filtex SupremeA1

Jun 8, 2005, Dr. Terry Ackerman

Ultracaine 2% 1:50,0002 carp: Infiltrated: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]3M Z100

Dec 14, 2005, Dr. Kim Black

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: mild bleeding on probing: mild bleeding on scaling: root surfaces generally rough: Oral B brush: dispensed: Ultra floss: Explained Periodontal Disease to patient and discussed treatment.OH much improved

Dec 14, 2005, Dr. Kim Black

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: Moderate bleedinggeneralized: moderate interproximally throughout: moderate bleeding with probe and scale: Oral B brush: Ultra floss: Explained Periodontal Disease to patient and discussed treatment.

Jun 19, 2006, Dr. Terry Ackerman

Ultracaine 2% 1:50,0002 carp: Infiltrated: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]Filtex SupremeA1

Dec 14, 2006, Dr. Terry Ackerman

Specific exam: cleanly broken MB cusp placed two pins and built up tooth again. Needs full coverage with PFM

Jun 20, 2007, Dr. Terry Ackerman

SeptanistSP4%2carps: [impr]Affinislight/heavy combo: [temp]composite: [TC]Tempbond: [Shade]A2: Teamwork Dental Lab

Jul 11, 2007, Dr. Terry Ackerman

No Anesthetic;: Insert Notes: Contactgood: Occlusionbite right on: Marginsvery good: Esthetics patient happy

Jul 11, 2007, Dr. Terry Ackerman

Insert Notes: Contactgood: Occlusionbite right on: Marginsvery good: Esthetics shade right on: Esthetics patient happy

Dec 17, 2007, Marj Brooks

RECALL: [MH]New Medical History completed: OH Fair; Mod.calc. Mod.plaque,generalized gingivitis: ScaledQ1: ScaledQ4: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after.Perio condition is improving, patient more effective with cleaning: Oral B brush: Ultra floss: Floss threaders

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 26: 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 26.

Procedure history

CodeToothDate
02111#26Aug 20, 2026
02144—Aug 20, 2026
01202—Dec 17, 2007
11112—Dec 17, 2007
43422—Dec 17, 2007
11101—Dec 17, 2007
12101—Dec 17, 2007
02112—Dec 17, 2007
27211#26Jul 11, 2007
00007—Jun 20, 2007
21402#26Dec 14, 2006
23323#26Dec 14, 2006
01204—Dec 14, 2006
27211#26Dec 14, 2006
23112#11Jun 19, 2006
23112#21Jun 19, 2006
01202—Dec 14, 2005
11112—Dec 14, 2005
11117—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
43423—Jun 8, 2005
11113—Jun 8, 2005
23322#26Jun 8, 2005
23322#27Jun 8, 2005
23322#26Dec 13, 2004
23322#27Dec 13, 2004
01103—Dec 13, 2004
02115—Dec 13, 2004
11113—Dec 13, 2004
43422—Dec 13, 2004
11113—Dec 13, 2004
43423—Dec 13, 2004
23112#11Dec 13, 2004
23112#21Dec 13, 2004