Synthetic determination specimen for the DeskGate v2.6.8 dental showcase. Zero live PHI.
| Decision: | Denied |
| Claim Reference: | DPM-CLM-55021934 |
| Member ID: | SYN-DM-550219 |
| Patient Name: | Okafor, Daniel R. |
| Date of Birth: | 07/22/1984 |
| Procedure (CDT): | D4341 x2 (UR, LR) |
| Date of service: | 03-Sep-2026 |
| Denial code: | DEN-PERIO-07 |
| Policy: | Dental Clinical Policy DCP-PERIO-2026 §2.1: scaling and root planing requires probing depths of 5 mm or more on at least four teeth per quadrant, with radiographic bone loss |
Missing / additional documentation requested:
Periodontal charting with probing depths for each tooth in the treated quadrants (dated within 12 months); Radiographs showing bone loss in the treated quadrants (dated); Tooth numbers treated in each quadrant; Periodontal diagnosis (stage and grade).
Appeal window: 180 days from this letter. Reconsideration is filed on the provider portal appeal form. The office's coordinator remains the filing actor.