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Jeanette Smith

Appointment passed

Crown on #17, upper right second molar · Crown appointment Monday Oct 5

  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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The appointment has passed. Rebook the patient. Source

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

  • 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

Check the chart again
CDCP requirements8 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
  • 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 #17 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 chart6 radiographs, 0 perio records, 7 notes

Radiographs

PANO
Mar 25, 2002
BW right #14, #15, #16, #17, #44, #45, #46, #47
Mar 25, 2002
A bitewing does not show the root tip.
BW left #24, #25, #26, #27, #34, #35, #36, #37
Mar 25, 2002
PA #17
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

None in the chart.

Clinical notes

Jun 17, 2004, Dr. Terry Ackerman

[Date]25/Mar/2002 exam, 1u sc, 1u pol: 2 bw taken and interpeted: panorex: smokes n/a: recommended pt come every 3 months for perio tx / pt. agrees

Jun 17, 2004, Dr. Terry Ackerman

[Date]02/Jul/2002 [Code]23322 [Type]Restoration [Desc]Permanent Molar Bond Tooth Coloured 2 Surface Rest. [Tooth]16 [Surf]LO [Mat]PL [Pvdr]T Septa 1:200000 2 carp: Tetric Filtek A1

Jun 17, 2004, Dr. Terry Ackerman

[Date]17/Jun/2004 APF topical fluoride foam application 1-min / advised pt not to eat drink rinse for 30 min after: exam, 1u sc, 1u pol: smokes n/a

Jun 17, 2004, Dr. Terry Ackerman

[Date]17/Jun/2004 Patient requires and has taken Antibiotics: exam, 1u sc, 1u pol: smokes n/a

Jun 17, 2004, Dr. Terry Ackerman

[Date]15/Dec/2003 Patient requires and has taken Antibiotics: smokes n/a: exam, 1-1/2u sc, 1/2u pol

Jun 17, 2004, Dr. Terry Ackerman

[Date]23/Feb/2004 [Code]23321 [Type]Restoration [Desc]Permanent Molar Bond Tooth Coloured 1 Surface Rest. [Tooth]47 [Surf]O [Mat]PL [Pvdr]T Septa 1:200000 1 carp: Z100 A2

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 17: 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 17.

Procedure history

CodeToothDate
02111#17Aug 20, 2026
02144—Aug 20, 2026
01103—Dec 7, 2004
11107—Dec 7, 2004
23321#47Feb 23, 2004
01202—Dec 15, 2003
11107—Dec 15, 2003
11111—Dec 15, 2003
11117—Dec 15, 2003
01202—Apr 7, 2003
11111—Apr 7, 2003
11107—Apr 7, 2003
11117—Apr 7, 2003
23322#16Jul 2, 2002
23322#26Jul 2, 2002
23221#27Jul 2, 2002
01103—Mar 25, 2002
02601—Mar 25, 2002
02142—Mar 25, 2002
11111—Mar 25, 2002
11101—Mar 25, 2002