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Kris Randal

Crown on #26, upper left first molar · Crown appointment Thursday Oct 1

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

Book the crown

You

Sun Life approved it on Sep 15, 2026. Book the crown by Sep 15, 2027.

Reach Kris at 905-555-0162, from the chart.

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 chart6 radiographs, 3 perio records, 10 notes

Radiographs

BW right #14, #15, #16, #17, #44, #45, #46, #47
Dec 13, 2004
BW left #24, #25, #26, #27, #34, #35, #36, #37
Dec 13, 2004
A bitewing does not show the root tip.
PA
Dec 13, 2004
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, 28 of 28 teeth
#26 323323
Perio chart Dec 14, 2006 uncertified draft
6 sites per tooth, 28 of 28 teeth
#26 323323
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

[CC]tooth#26: [CC]throbbing pain: [CC]did not prevent sleep: [CC]duration 2 days: [CC]xray(s) taken

Dec 13, 2004, Dr. Terry Ackerman

[MH]New Medical History completed: INTRAORAL EXAM: WNL: EXTRAORAL EXAM: WNL: OH Good,light calc.light plaque,mild generalized gingivitis: Scaled: Scaled all quads, profhy,floss: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after

Jun 8, 2005, Dr. Terry Ackerman

SeptanestSP4%3carps: Infiltrated: Palatal Infiltration: : placed rubber dam: created access: shaped with files: Peso Burssize 2: Rinsed with Sodium Hypochlorite 50%: MB25: DB25: Palatal40: MB20mm: DB22mm: Palata25mml: GP0425: Backfill23gauge

Jun 8, 2005, Dr. Terry Ackerman

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

Dec 14, 2005, Marj Brooks

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: OH Very Good,light calc.no plaque; NO PROBE this time

Jan 19, 2006, Dr. Terry Ackerman

Lidocaine 2% 1:100,000 2 carp: Mandibular Block & Long Buccal: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]Filtex SupremeA1

Dec 14, 2006, Marj Brooks

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: OH Good,light calc.light plaque,mild 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 14, 2006, Marj Brooks

#26 should have pst,BU,Crn for protections

Dec 17, 2007, Dr. Terry Ackerman

SeptanistSP4%2carps: [impr]Affinislight/heavy combo: [temp]composite: [TC]Tempbond: [Shade]A1: Protec Lab

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
25731#26Dec 17, 2007
23602#26Dec 17, 2007
00007—Dec 17, 2007
01202—Dec 14, 2006
11113—Dec 14, 2006
43421—Dec 14, 2006
11101—Dec 14, 2006
12101—Dec 14, 2006
25731#26Dec 14, 2006
23602#26Dec 14, 2006
27211#26Dec 14, 2006
23323#46Jun 19, 2006
23312#45Jun 19, 2006
01202—Dec 14, 2005
11112—Dec 14, 2005
43422—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
33131#26Jun 8, 2005
23312#25Jun 8, 2005
23322#26Jun 8, 2005
02144—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11101—Dec 13, 2004
12101—Dec 13, 2004
01103—Dec 13, 2004
23323#46Dec 13, 2004
23312#45Dec 13, 2004
23312#25Dec 13, 2004
23322#26Dec 13, 2004
39202—Dec 13, 2004
02111—Dec 13, 2004