Demo with fictional patients.
View as
Board

Bob Miller

Send by Oct 20

Crown on #36, lower left first molar · Crown appointment Tuesday Oct 27

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

Fix the paperwork

You

The chart changed after Ophi last compared it with past decisions on Sep 27, 2026, so no denial risk is shown.

  • Confirm the procedure code against the CDCP grid

    Why

    27215 is a crown code, but it is not one of the 3 crown codes on the 2026 ON grid (27201, 27211, 27301). The grid is the authority here, so check the code before this goes out.

    Required by Grid Schedule B — 2.0 Restoration, crowns CDCP Dental Benefit Grid — Ontario, General Practitioners and Specialists, 2026 Schedule B — 2.0 Restoration, crowns 27201, 27211, 27301 — preauthorization required Open the source document

Dr. Terry Ackerman can confirm the clinical criteria now, in parallel.

Check the chart again
CDCP requirements9 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
  • 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.

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

What Ophi read in the chart4 radiographs, 4 perio records, 9 notes

Radiographs

PA
Dec 13, 2004
PA #36
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, 26 of 28 teeth
#36 434433
Perio chart Dec 14, 2005 uncertified draft
6 sites per tooth, 26 of 28 teeth
#36 433323
Perio chart Dec 14, 2006 uncertified draft
6 sites per tooth, 26 of 28 teeth
#36 323434
Perio chart Aug 20, 2026
6 sites per tooth, 28 of 28 teeth, current until Aug 20, 2027
#36 323323

Clinical notes

Jun 22, 2005, Dr. Terry Ackerman

Ultracaine 2% 1:50,0003 carp: Infiltrated: Palatal Infiltration: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchUltraDent-Ultra-etch 45%: [COMP]Single UsePrimer & BondOptibond Solo: [COMP]Filtex SupremeA1

Jun 22, 2005, Dr. Terry Ackerman

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

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, Dr. Terry Ackerman

SeptanestSP4%2carps: Mandibular block: placed rubber dam: created access: shaped with files: Rinsed with Sodium Hypochlorite 50%: Trial point: Canals1: Confirmed length with PA 22mm : filled with warm GP (vertical condensation technique):

Jan 19, 2006, Dr. Terry Ackerman

[PST]sized to parapostgreen

Jan 19, 2006, Dr. Terry Ackerman

Recemented crown with Tempbond

Dec 14, 2006, 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, Marj Brooks

RECALL: [MH]New Medical History completed: 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

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 36: 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 36.

Procedure history

CodeToothDate
02111#36Aug 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
79951#36Dec 17, 2007
27215#36Dec 17, 2007
01202—Dec 14, 2006
11113—Dec 14, 2006
43423—Dec 14, 2006
11101—Dec 14, 2006
12101—Dec 14, 2006
29301—Jun 19, 2006
33111#35Jun 19, 2006
25731#35Jun 19, 2006
29101—Jun 19, 2006
01202—Dec 14, 2005
11112—Dec 14, 2005
43422—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
23111#13Jun 22, 2005
23111#12Jun 22, 2005
23111#11Jun 22, 2005
23111#21Jun 22, 2005
23111#22Jun 22, 2005
23111#23Jun 22, 2005
23111#13Dec 13, 2004
23111#12Dec 13, 2004
23111#11Dec 13, 2004
23111#21Dec 13, 2004
23111#22Dec 13, 2004
23111#23Dec 13, 2004
01103—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11101—Dec 13, 2004
12101—Dec 13, 2004
02115—Dec 13, 2004
29301—Dec 13, 2004
33111#35Dec 13, 2004
25731#35Dec 13, 2004
29101—Dec 13, 2004