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John Provost

Send by Oct 15

Crown on #26, upper left first molar · Crown appointment Thursday Oct 22

  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, 3 perio records, 12 notes

Radiographs

PANO
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, 32 of 28 teeth
#26 535545
Perio chart Dec 14, 2005 uncertified draft
6 sites per tooth, 32 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: OH Poor; Abundant calc; Abundant Calc; mod/severe generalized gingivitis: Discussed w/p OH issues,risk of disease progression/tooth mobility/loss : recommended pt come every 3 months for perio tx / pt. agrees: (sub)-abundant lingual mandible and facial maxilla: (supra)-heavy

Jun 8, 2005, Marj Brooks

moderate bleeding with probe and scale: root surfaces generally rough: root surface rough at CEJ: sc2u

Jun 8, 2005, Dr. Terry Ackerman

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

Jun 22, 2005, Dr. Terry Ackerman

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

Jun 22, 2005, Dr. Terry Ackerman

Patient requires and has taken Antibiotics

Jun 22, 2005, Dr. Terry Ackerman

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

Dec 14, 2005, Marj Brooks

RECALL: No c/c:No significant changes to e/o,i/o,soft tissue: OH Poor; Abundant calc; Abundant Calc; mod/severe generalized gingivitis: ScaledQ2: ScaledQ3: APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after OH has improved significantly

Dec 14, 2006, Marj Brooks

moderate bleeding with probe and scale: root surfaces generally rough: sc2u Patient working hard at improving condition of oral cavity

Jun 20, 2007, Dr. Terry Ackerman

prepared site via atraumatic extraction of 26;: [NBC]Replace Select yellow placed; : freeze dried bone placed in socket: Alloder m membrane covering sutured 3.0 Silk

Jun 20, 2007, Dr. Terry Ackerman

prepared site via atraumatic extraction of 26;: [NBC]Replace Select yellow placed; packed with freeze dried bone; alloderm membrane placed over top; 3.0 silk sutures

Dec 17, 2007, Dr. Terry Ackerman

Removed healing cap;placed implant abutment; impression Reprosil light/heavy combo; replaced healing cap till insert

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
00002—Dec 17, 2007
72311#26Jun 20, 2007
79951#26Jun 20, 2007
11112—Dec 14, 2006
43422—Dec 14, 2006
72311#26Dec 14, 2006
79951#26Dec 14, 2006
00006—Dec 14, 2006
00002—Dec 14, 2006
27215#26Dec 14, 2006
01202—Dec 14, 2005
11113—Dec 14, 2005
43423—Dec 14, 2005
11101—Dec 14, 2005
12101—Dec 14, 2005
27211#14Jun 22, 2005
43422—Jun 8, 2005
11112—Jun 8, 2005
33121#14Jun 8, 2005
23602#14Jun 8, 2005
25731#14Jun 8, 2005
00007—Jun 8, 2005
02601—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
11112—Dec 13, 2004
43422—Dec 13, 2004
72321#26Dec 13, 2004
33121#14Dec 13, 2004
25731#14Dec 13, 2004
23602#14Dec 13, 2004
27211#14Dec 13, 2004
01103—Dec 13, 2004
11101—Dec 13, 2004
12101—Dec 13, 2004