Dental Insurance Carrier

Re: John Doe

To Whom it may Concern:

Your insured ____________ sought treatment at our office on ______.

Mr./Ms. _________ reported concerns of tooth grinding and clenching, tooth pain, head, neck and facial pain (including headache and medically-diagnosed migraine), as well as joint pain and clicking.

Examination revealed:
    * Limited range of mandibular motion:
         ___ mm on opening
         ___ mm left side movement
         ___ mm right side movement
    * Moderate-severe pain on palpation of the muscles of mastication
    * Moderate-severe temporomandibular joint disorder (TMD, with pain/clicking)
    * Pathological tooth wear.
    * Vertical bone loss patterns seen radiographically
    * Biting stress mobility and fremitis.
    * Abfractures of teeth at the gum line

Treatment, with CDT-3 codes, includes insertion of an FDA approved device, the NTI-tss appliance submitted with [CDT-3 code, D7880 oral occlusal orthotic] OR [CDT-3 code D9940 occlusal guard, by report].

Once the pain problem has resolved Mr./Ms. ____________ will have a complete occlusal adjustment/selective grinding (CDT-3 Code D-9951) to establish a stable, functional occlusion. This will eliminate the forces which are causing the fractures, tooth wear and tooth-loosening. It will also make it possible for ______ to chew properly.

This report provides you with information demonstrating the need for treatment. All of the necessary patient information is provided herein for expedient claims processing.

Sincerely,
 

[NTI-tss Provider]