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- pt E. Marti, 42f, insurance CSS - tooth 36, deep caries, prev filling '19 - pain on cold, no percussion tenderness - X-ray: periapical shadow, pulp necrosis - plan: RCT + full crown, 2 sessions - pre-auth needed, codes C.4230 + C.5310
Insurance Assessment — Patient Marti, E.
Patient presents with deep caries at tooth 36 with a previous composite restoration (2019). Clinical exam reveals sensitivity to cold stimulus without percussion tenderness…
Radiographic findings confirm a periapical radiolucency consistent with pulpal involvement. Recommended treatment consists of endodontic therapy followed by prosthetic restoration…
Billing codes: C.4230, C.5310.
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Insurance Assessment — Patient Marti, E.
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Insurance Assessment — Patient Marti, E.
Patient presents with deep caries at tooth 36 and sensitivity to cold. Previous composite restoration placed in 2019. No percussion tenderness reported. Clinical history otherwise unremarkable.
Intraoral examination reveals a deep carious lesion at tooth 36. Radiographic imaging confirms a periapical radiolucency consistent with pulpal necrosis. No evidence of root fracture or extensive bone loss.
Recommended two-stage treatment: endodontic therapy followed by prosthetic restoration with a full-coverage crown. The patient was informed of risks, benefits, and alternatives.
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Each report follows a clear structure insurers expect: complaint, findings, diagnosis, treatment plan, and consent.
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