Prior Authorization Request (Endodontic Procedure)

Document Header

Document Title: Prior Authorization Request — Endodontic Procedure

Date of Request: [Date of request]

Request Urgency: [routine / urgent]

Payer Name: [Payer name]

Plan Type: [Plan type]

Prior Auth Reference #: [Reference number, if applicable]

Patient Name: [Patient full name]

Date of Birth: [DOB]

Member/Subscriber ID: [Member ID]

Group #: [Group number]

Requesting Provider: [Provider name]

Provider Credentials: [Credentials]

NPI: [NPI]

Practice Address: [Street, City, State, ZIP]

Phone: [Phone]

Fax: [Fax]

Executive Summary

• Tooth: [Tooth number with arch/side]
• Diagnoses: Pulpal — [Pulpal diagnosis]; Apical — [Apical diagnosis]
• Primary clinical driver: [pain / infection / swelling / radiographic lesion]
• Strongest objective finding: [Single strongest objective finding with quantified or comparative detail]
• Requested procedure: [Procedure type] [CDT code(s)]
• Medical necessity: [One-sentence statement of why treatment is medically necessary now]

Chief Complaint and Symptom History

[Chief complaint in patient's own words] (Use quotation marks if directly quoting.)

[Symptom onset, duration, and progression, including timeline and any changes over time]

[Triggers and characteristics: thermal sensitivity, biting/chewing triggers, spontaneous or nocturnal pain, severity, functional impact]

[Response to medications or prior care: analgesics, antibiotics, temporary measures and their effectiveness] (Include only if applicable.)

[Tooth-specific history: recent restoration, deep caries, trauma, prior endodontic treatment, cracked tooth suspicion] (Include only if applicable.)

[Relevant medical context affecting planning or alternatives] (Include only if it alters options or timing.)

(If history is limited or the patient cannot recall key details, document this explicitly.)

Clinical Examination and Testing

Extraoral and Intraoral Examination

• Facial swelling/asymmetry/lymphadenopathy: [present with description / absent]
• Sinus tract: [present with location and drainage description / absent]
• Vestibular tenderness/fluctuance: [present with description / absent]
• Caries or defective restorations: [Description of depth and proximity to pulp]
• Fracture indicators: [Transillumination or staining findings] (Include only if performed.)
• Other relevant findings: [Additional positive or pertinent negative findings]

Periodontal Findings

• Probing depths: [Sites and depths; note worst site with measurement]
• Furcation involvement: [none / Grade I / Grade II / Grade III] (If multi-rooted tooth.)
• Mobility: [Miller grade 0 / I / II / III]
• Suppuration/bleeding on probing: [present / absent]

Pulp Sensibility Testing

(Compare responses to control teeth. Describe quality of response: none, normal, exaggerated, lingering. If testing was not performed or unreliable, explain why.)

Test	Tooth Tested	Result (quality and duration)	Control Comparison
Cold	[Tooth #]	[Result]	[Control tooth # and response]
EPT	[Tooth #]	[Result]	[Control tooth # and response]
Heat	[Tooth #]	[Result]	[Control tooth # and response]

Periapical Testing

Test	Tooth Tested	Result	Control Comparison
Percussion	[Tooth #]	[Result]	[Control tooth # and response]
Palpation	[Tooth #]	[Result]	[Control tooth # and response]
Bite test	[Tooth #]	[Result; note cusp or segment if applicable]	[Control tooth # and response]
Sinus tract tracing	[Tooth #]	[Tracing method and result]	—

(Include sinus tract tracing row only if sinus tract present.)

Imaging Findings

• Images submitted: [Periapical / Bitewing / Panoramic] — [Date(s)] — [Number of images/angles]
• Diagnostic adequacy: [Image(s) include entire tooth and apex / Additional angle submitted for diagnostic clarity / Note limitations if any]
• Periapical status: [PDL space status, radiolucency size and location, lamina dura changes] (Use qualified language such as "findings consistent with...")
• Caries/restoration status: [Depth relative to pulp; secondary caries if present]
• Root/canal anatomy: [Calcification, curvature, resorption, number of canals suspected]

CBCT: [Clinical justification for 3D imaging and impact on management] (Include only if CBCT was obtained.)

Diagnoses

Pulpal Diagnosis: [symptomatic irreversible pulpitis / pulp necrosis / previously treated / previously initiated therapy / normal pulp]

[One-sentence justification linking key subjective and objective findings to the pulpal diagnosis]

Apical Diagnosis: [symptomatic apical periodontitis / asymptomatic apical periodontitis / acute apical abscess / chronic apical abscess / condensing osteitis / normal apical tissues]

[One-sentence justification linking key subjective and objective findings to the apical diagnosis]

(Both pulpal and apical diagnoses are required. If either cannot be determined, flag for provider review.)

Medical Necessity Statement

[Condition and risks if untreated: pain or infection progression, abscess formation, potential tooth loss]

[Rationale for endodontic therapy based on diagnoses and objective evidence; tooth restorability and strategic/functional value]

[Alternatives considered and why not appropriate: extraction with replacement options, observation, palliative care, restorative-only approaches; provide clinical reasons] (If urgent, explain timing factors: acute pain, swelling, systemic signs, or functional impairment.)

Requested Procedure

Procedure Type: [initial nonsurgical root canal therapy / nonsurgical retreatment / vital pulp therapy]

Tooth Number and Type: [Tooth # and type]

CDT Code(s): [CDT code(s)]

Planned Visits: [single-visit / multi-visit with rationale]

Definitive restoration will be required for long-term success and will be billed separately.

Referral coordination: [Provider performing endodontic procedure versus definitive restoration] (Include only if applicable.)

Supporting Documentation

• Pre-operative periapical radiograph(s) — Tooth [#] — [Date]
• Additional radiographs or angles — Tooth [#] — [Date] (If applicable.)
• Clinical photographs — Tooth [#] — [Date] (If applicable.)
• Relevant periodontal charting — [Date] (If applicable.)
• Prior treatment records — [Date] (If retreatment.)

(If a typically required item is not included, state reason. Post-operative radiographs will be obtained upon treatment completion and submitted as required.)

Provider Attestation

I attest that the findings and diagnoses documented herein are based on a direct clinical examination, diagnostic testing, and imaging review performed by me or under my supervision, and that the requested procedure is medically necessary as described.

Provider Signature: [Signature]

Printed Name and Credentials: [Name and credentials]

Date: [Date]

Direct Phone for Peer-to-Peer Review: [Phone]

Best Contact Times: [Times]