Preauthorization documentation narrative
Reference asm_2a8e39b2b77ed1fd -- ABELDent lab (Fictional Data) -- prepared 2026-10-08

1. Proposed treatment
Procedure 27211 -- Porcelain/Ceramic/Polymer Glass Fused Metal Based Crown.
Tooth #16 (FDI), the upper right first molar.
Provider: Dr. Terry Ackerman.
Planned date: 2004-07-14. Appointment: 2026-10-13.

2. Treatment plan status
Completed treatment on record:
- 32313 #16 (d,m,l), 2004-07-13 -- Permanent 3 Canal Emergency Pulpectomy/Retained Primary
- 99111, 2004-12-07 -- Commercial Laboratory Procedures
- 02111 #16, 2026-08-20 -- Single Periapical Film
- 02144, 2026-08-20 -- Four Bitewings
No other planned treatment on record.
Treatment plan plan_1 dated 2004-07-13: pending 27211; completed none.

3. Clinical findings recorded in the chart
"Recall exam. Tooth 16: 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 16."
-- clinical note dated 2026-08-20, Dr. Terry Ackerman

4. Clinician assessment of CDCP crown criteria
Dr. Terry Ackerman confirmed on 2026-09-24: All basic treatment for active caries and periodontal disease is complete. [guide 6.3.5 Crowns]
Dr. Terry Ackerman confirmed on 2026-09-24: Crown-to-root ratio 1:1 or better. [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: Tooth meets the CDCP "extensively restored" definition for its type. [guide 6.3.5 Crowns -- extensively restored]
  Definition applied (posterior tooth, not endodontically treated): Non-endodontically treated: 5 continuous surfaces
Dr. Terry Ackerman confirmed on 2026-09-24: Adequate ferrule (1.5 mm). [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: Restoration margin at least 3 mm from the alveolar crest. [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: Mesio-distal space equivalent to the natural tooth. [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: Absence of active periodontal disease at the requested tooth. [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: No crown lengthening, root resectioning or orthodontics required. [guide 6.3.5 Crowns -- restorability]
Dr. Terry Ackerman confirmed on 2026-09-24: No furcation involvement. [guide 6.3.5 Crowns -- restorability]

5. Supporting documentation
- Claim form (CDA/CLHIA standard, or computer-generated treatment form): computer-generated treatment form (file 01 of this packet). Rule claim_form; matrix Restorative services -- Claim form: Yes.
- Treatment plan details -- all relevant completed and pending treatment: treatment plan plan_1, captured 2004-07-13. Rule tx_plan_details; matrix Restorative services -- Tx plan: Yes (footnote 1).
- Dated periapical radiograph of the requested tooth, within 12 months: periapical radiograph of #16, captured 2026-08-20. Rule radiograph_pa; matrix Restorative services -- PA+BW (R&L) <=12mo: Yes; also guide 6.1.2 Radiograph standards.
- Dated bitewing radiographs, right and left, within 12 months: bitewing radiograph, right (#14, #15, #16, #17, #44, #45, #46, #47), captured 2026-08-20; bitewing radiograph, left (#24, #25, #26, #27, #34, #35, #36, #37), captured 2026-08-20. Rule radiograph_bw; matrix Restorative services -- PA+BW (R&L) <=12mo: Yes.
- Dated complete periodontal chart, within 12 months: periodontal chart, 168 sites, examiner T, captured 2026-08-20. Rule perio_chart; matrix Restorative services -- Complete perio chart <=12mo: Yes, crowns only (footnote 7).
- All basic treatment for active caries and periodontal disease completed: clinician assertions recorded in section 4. Rule basic_treatment_complete; guide 6.3.5 Crowns.
- Restorability criteria confirmed by the treating dentist: clinician assertions recorded in section 4. Rule restorability; guide 6.3.5 Crowns -- restorability.
- Tooth meets the "extensively restored" definition: clinician assertions recorded in section 4. Rule extensively_restored; guide 6.3.5 Crowns -- extensively restored.

Prepared with Ophi for review by the treating provider. Documentation completeness assessed against cdcp-preauth-crowns 2026.01.26 (content hash 5455eaf3c9f6) on 2026-10-08. The treating dentist is solely responsible for clinical content and the decision to submit.
