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Valerie Espenhain

Visit needed by Oct 21

Crown on #46, lower right first molar · Crown appointment Wednesday Oct 28

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

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You

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

Needs the patient

  • Complete a 6-site periodontal chart (all present teeth)

    Why

    A crown request needs a gum chart from the last 12 months, with all six points measured on every tooth.

    Required by 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

At the desk

  • Confirm: Treatment plan details stated in the clinical note

    “Plan: PFM crown 46.”
    Does the note say this?
    Why

    Ophi read this in the clinical note. It counts once a person confirms the note really says it.

    Required by 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

Check the chart again
CDCP requirements7 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
  • Unsatisfied
    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
    Complete periodontal chart, 6 sites per tooth, all present teeth: no periodontal chart on record | PSR for every sextant plus 6-site measurements for the requested tooth: no PSR on record; no 6-site measurements for #46 on record
  • 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, 2 perio records, 10 notes

Radiographs

PA
Dec 13, 2004
PA
Dec 13, 2004
PA #46
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
A bitewing does not show the root tip.
BW left #24, #25, #26, #27, #34, #35, #36, #37
Aug 20, 2026, current until Aug 20, 2027

Periodontal charting

Perio chart Dec 13, 2004 uncertified draft
6 sites per tooth, 28 of 28 teeth
#46 333333
Perio chart Dec 14, 2005 uncertified draft
6 sites per tooth, 28 of 28 teeth
#46 323323

Clinical notes

Dec 13, 2004, Dr. Terry Ackerman

[MH]New Medical History completed: OH Good,light calc.light plaque,mild generalized gingivitis: EXTRAORAL EXAM: WNL: INTRAORAL EXAM: WNL

Jun 8, 2005, Dr. Terry Ackerman

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

Jun 8, 2005, Dr. Terry Ackerman

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

Jun 22, 2005, Dr. Terry Ackerman

Insert Notes: no anesthetic

Jun 22, 2005, Dr. Terry Ackerman

Insert Notes: Contactgood: Occlusionbite needed slight adj: Marginsvery good: Estheticsshade right on: Estheticspatient happy

Dec 14, 2005, Dr. Kim Black

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

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, Marj Brooks

RECALL: OH Good,light calc.light plaque,OH very good; probe next time;: 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

Lidocaine 2% 1:100,000 2 carp: Infiltrated: [COMP]Placed RD: [COMP]prepared tooth/teeth: [COMP]acid etchPulpdent Etch-Rite 38%: [COMP]Single UsePrimer & BondBisco 1step: [COMP]Filtex SupremeA1

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 46: 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 46.

Procedure history

CodeToothDate
02111#46Aug 20, 2026
02144—Aug 20, 2026
23313#25Dec 17, 2007
23322#27Dec 17, 2007
01202—Dec 14, 2006
11112—Dec 14, 2006
43422—Dec 14, 2006
11101—Dec 14, 2006
12101—Dec 14, 2006
23313#25Dec 14, 2006
23322#27Dec 14, 2006
23313#14Jun 19, 2006
01202—Dec 14, 2005
11112—Dec 14, 2005
43422—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
27211#46Jun 22, 2005
99111—Jun 22, 2005
25731#46Jun 8, 2005
23602#46Jun 8, 2005
25731#46Dec 13, 2004
23602#46Dec 13, 2004
27211#46Dec 13, 2004
02115—Dec 13, 2004
23313#14Dec 13, 2004
01103—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11101—Dec 13, 2004
12101—Dec 13, 2004
02116—Dec 13, 2004