Core buildup narrative example - decay, crown delivered at a separate visit
The straightforward case: substantial decay, walls gone, and the crown seated at a later appointment.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - CORE BUILDUP, TOOTH #19
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Tooth #19 has lost natural tooth structure to decay; 50% or more of the natural tooth structure is decayed or missing. The tooth is vital.
A pre-operative periapical radiograph is on file and submitted with this claim. A post-operative radiograph showing the completed buildup is on file and submitted with this claim.
A core buildup (D2950) was placed on tooth #19 in preparation for a crown delivered at a separate visit.
2 axial walls were missing after caries removal and preparation. Sound dentin remaining circumferentially after preparation: less than 3 mm. The buildup was necessary to retain the final restoration.
No post-and-core service was reported on this tooth on this date of service.
Attachments: pre-operative periapical radiograph (dated); post-operative radiograph (dated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 232 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D2950 #19 for crown, separate visit; decay, >=50% structure loss; <3mm dentin after prep; buildup necessary to retain the final restoration; no post/core same DOS. Pre-op PA + post-op x-ray attached.
Before you use this, your chart must show:
- •the Universal tooth number of the tooth built up
- •the final restoration the buildup supports, and its delivery date
- •the decay or fracture that removed the tooth structure
- •whether the tooth is vital or endodontically treated
- •how much natural tooth structure is decayed or missing
- •a chart entry recording that the buildup was necessary to retain the final restoration
- •the sound dentin remaining circumferentially after preparation, where measured
- •the number of axial walls missing after preparation
- •a pre-operative image of the tooth
- •a post-operative image showing the completed buildup in place
Satisfies the published criteria of:
Not fully met for Delta Dental (Delta Dental Ins. enterprise) (3 of 4).
Criteria met is not coverage; the plan contract controls.
Core buildup narrative example - fracture with less than 3 mm of sound dentin
A fracture case documented against Guardian's dentin threshold, with photographs at both stages.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - CORE BUILDUP, TOOTH #30
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Tooth #30 has lost natural tooth structure to fracture; 50% or more of the natural tooth structure is decayed or missing. The tooth is vital.
A pre-operative periapical radiograph and a pre-operative photograph are on file and submitted with this claim. A post-operative radiograph and a post-operative photograph showing the completed buildup are on file and submitted with this claim. The photographs were taken within the past 12 months.
A core buildup (D2950) was placed on tooth #30 in preparation for a crown delivered at a separate visit.
3 axial walls were missing after caries removal and preparation. Sound dentin remaining circumferentially after preparation: less than 3 mm. The buildup was necessary to retain the final restoration.
No post-and-core service was reported on this tooth on this date of service.
Attachments: pre-operative periapical radiograph and photograph (dated); post-operative radiograph and photograph showing the buildup in place (dated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 241 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D2950 #30 for crown, separate visit; fx, >=50% structure loss; <3mm dentin after prep; buildup necessary to retain the final restoration; no post/core same DOS. Pre-op PA+photo + post-op x-ray+photo attached.
Before you use this, your chart must show:
- •the Universal tooth number of the tooth built up
- •the final restoration the buildup supports, and its delivery date
- •the decay or fracture that removed the tooth structure
- •whether the tooth is vital or endodontically treated
- •how much natural tooth structure is decayed or missing
- •a chart entry recording that the buildup was necessary to retain the final restoration
- •the sound dentin remaining circumferentially after preparation, where measured
- •the number of axial walls missing after preparation
- •a pre-operative image of the tooth
- •a post-operative image showing the completed buildup in place
- •the date the photographs were taken
Satisfies the published criteria of:
- Aetna
- Cigna
- Delta Dental (Delta Dental Ins. enterprise)
- Guardian
Criteria met is not coverage; the plan contract controls.
Core buildup narrative example - endodontically treated tooth, no post and core
A root-treated tooth built up without a post, so the same-date post-and-core exclusion is stated on the record.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - CORE BUILDUP, TOOTH #3
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Tooth #3 has lost natural tooth structure to decay and fracture; 50% or more of the natural tooth structure is decayed or missing. The tooth is endodontically treated.
A pre-operative periapical radiograph is on file and submitted with this claim. A post-operative radiograph showing the completed buildup is on file and submitted with this claim.
A core buildup (D2950) was placed on tooth #3 in preparation for a crown delivered at a separate visit.
2 axial walls were missing after caries removal and preparation. Sound dentin remaining circumferentially after preparation: less than 3 mm. The buildup was necessary to retain the final restoration.
No post-and-core service was reported on this tooth on this date of service.
Attachments: pre-operative periapical radiograph (dated); post-operative radiograph (dated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 238 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D2950 #3 for crown, separate visit; decay and fx, >=50% structure loss; <3mm dentin after prep; buildup necessary to retain the final restoration; no post/core same DOS. Pre-op PA + post-op x-ray attached.
Before you use this, your chart must show:
- •the Universal tooth number of the tooth built up
- •the final restoration the buildup supports, and its delivery date
- •the decay or fracture that removed the tooth structure
- •whether the tooth is vital or endodontically treated
- •how much natural tooth structure is decayed or missing
- •a chart entry recording that the buildup was necessary to retain the final restoration
- •the sound dentin remaining circumferentially after preparation, where measured
- •the number of axial walls missing after preparation
- •a pre-operative image of the tooth
- •a post-operative image showing the completed buildup in place
Satisfies the published criteria of:
Not fully met for Delta Dental (Delta Dental Ins. enterprise) (3 of 4).
Criteria met is not coverage; the plan contract controls.
Core buildup narrative example - same-day CAD-CAM crown, the one published exception
The single same-day path Cigna publishes; a same-day conventional crown is excluded by the same rule.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - CORE BUILDUP, TOOTH #14
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Tooth #14 has lost natural tooth structure to decay; 50% or more of the natural tooth structure is decayed or missing. The tooth is vital.
A pre-operative periapical radiograph is on file and submitted with this claim. A post-operative photograph showing the completed buildup is on file and submitted with this claim. The photographs were taken within the past 12 months.
A core buildup (D2950) was placed on tooth #14 in preparation for a same-day CAD-CAM crown.
2 axial walls were missing after caries removal and preparation. Sound dentin remaining circumferentially after preparation: less than 3 mm. The buildup was necessary to retain the final restoration.
No post-and-core service was reported on this tooth on this date of service.
Attachments: pre-operative periapical radiograph (dated); post-operative photograph showing the buildup in place (dated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 227 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D2950 #14 for same-day CAD-CAM; decay, >=50% structure loss; <3mm dentin after prep; buildup necessary to retain the final restoration; no post/core same DOS. Pre-op PA + post-op photo attached.
Before you use this, your chart must show:
- •the Universal tooth number of the tooth built up
- •the final restoration the buildup supports, and its delivery date
- •the decay or fracture that removed the tooth structure
- •whether the tooth is vital or endodontically treated
- •how much natural tooth structure is decayed or missing
- •a chart entry recording that the buildup was necessary to retain the final restoration
- •the sound dentin remaining circumferentially after preparation, where measured
- •the number of axial walls missing after preparation
- •a pre-operative image of the tooth
- •a post-operative image showing the completed buildup in place
- •the date the photographs were taken
Satisfies the published criteria of:
- Cigna
- Delta Dental (Delta Dental Ins. enterprise)
- Guardian
Not fully met for Aetna (1 of 2).
Criteria met is not coverage; the plan contract controls.
