Examples of Dental Narratives for Insurance

If you have been practicing dentistry for any length of time, you know the feeling. You finish a complex restoration, the patient leaves with a smile, and then… the insurance check arrives, and it is significantly smaller than expected. Or worse, it doesn’t arrive at all, accompanied only by a cryptic explanation of benefits (EOB) stating, “Procedure not covered based on submitted documentation.”

In the world of dental insurance, the procedure code (the CDT code) tells the insurance company what you did. But the dental narrative tells them why you did it. And in many cases, the “why” is the only thing that separates a paid claim from a denied one.

Writing these narratives can feel tedious, but it is one of the most important skills in a modern dental practice. A well-written narrative bridges the gap between clinical necessity and administrative approval. It translates the clinical situation inside a patient’s mouth into the language of insurance policies.

In this guide, we will explore what makes a narrative effective and provide you with a wealth of realistic examples you can adapt for your own practice. Whether you are dealing with complex periodontal cases, congenital anomalies, or medically necessary services, this is your go-to resource.

Why Dental Insurance Narratives Matter More Than Ever

Before we dive into the examples, let’s talk about why this documentation is so critical. Insurance companies process thousands of claims a day. While software handles the initial sorting, many claims are flagged for manual review. This usually happens when a procedure is unusual, expensive, or falls outside the standard “frequency” limits set by the plan.

When a human adjuster picks up your claim, they have a limited amount of time to make a decision. They don’t know your patient. They didn’t see the x-rays. All they have is the paper (or digital file) in front of them.

A strong narrative serves three purposes:

1. Justification: It proves medical necessity according to the patient’s specific plan guidelines.

2. Clarity: It explains why a standard approach (like a simple filling) wasn’t appropriate, and why a more complex (and often more expensive) procedure was required.

3. Speed: It answers the adjuster’s questions before they even ask them, reducing the need for back-and-forth communication and appeals.

The Anatomy of a Perfect Dental Narrative

To write a great narrative, you don’t need to write a novel. You need a structured, factual, and concise summary. Think of it as telling a short story with a beginning, middle, and end.

The Beginning (The Diagnosis): What is the problem?
The Middle (The Clinical Evidence): How do you know it’s a problem?
The End (The Treatment Plan): What are you doing to fix it, and why this specific method?

Here are the five essential components every narrative should include:

1. Chief Complaint (CC): What brought the patient in? Use their words when possible (e.g., “Patient complains of pain when drinking cold water on the lower left side”).

2. Relevant History: Include medical history if it impacts treatment (e.g., GERD, diabetes, medication usage) and dental history (e.g., “Tooth #19 has a large existing amalgam with recurrent decay”).

3. Clinical Findings: Describe what you saw and the diagnostic aids you used. Be specific about tooth numbers, surfaces, and measurements (e.g., periodontal probing depths, size of lesion on radiograph).

4. Diagnosis/Rationale: State the diagnosis clearly. Then, explain why the specific procedure you are billing for is the only acceptable option. This is where you justify a crown over a filling, or a surgical extraction over a simple one.

5. Supporting Documentation: Mention the attachments. “Please see attached periapical radiograph dated 10/12/2023” or “Refer to intraoral photos showing the fractured distal cusp.”

Important Note for Readers: Insurance companies do not pay for “elective” or “cosmetic” procedures. Your narrative must constantly emphasize function and health. Words like “chewing efficiency,” “prevention of further breakdown,” “occlusal stability,” and “pain relief” are powerful.

20+ Real-World Examples of Dental Narratives for Insurance

Now, let’s get to the practical part. Below are categorized examples of narratives for the most common—and most commonly denied—dental procedures.

Category 1: Restorative Narratives (Crowns, Core Buildups, etc.)

This is the most frequent area where narratives are required. Insurance companies often want to pay for a large filling (amalgam or composite) instead of a crown, as it is cheaper. You must prove why a filling would fail.

Example 1: Crown (D2740) Due to Decay

Clinical Situation: Tooth #18 has extensive decay undermining the cusps.

Narrative: “Patient presented with a chief complaint of roughness on the lower right tooth. Clinical examination revealed a large, defective amalgam restoration on tooth #18 with recurrent caries extending into the mesial and distal pits. Upon excavation of the caries, it was determined that the remaining tooth structure was insufficient to support a new intracoronal restoration. The decay compromised the strength of the buccal and lingual cusps, placing them at high risk for fracture under normal occlusal forces. A full-coverage crown (D2740) is medically necessary to cuspally protect the remaining tooth structure, restore function, and prevent the need for a more extensive and costly procedure in the future, such as root canal therapy or extraction. Radiographic evidence is attached.”

Example 2: Crown (D2740) Due to Fracture

Clinical Situation: Tooth #30 has a cracked tooth.

Narrative: “The patient reported sharp pain upon biting on the lower right side. Examination of tooth #30 revealed a visible fracture line extending from the mesial marginal ridge into the pulpal floor. An existing MO amalgam was present. Transillumination confirmed the crack. Due to the propagation of the crack, the tooth is at imminent risk of splitting. A full-coverage crown is necessary to cuspally bind the tooth, prevent the crack from extending into the pulp or root, and restore full masticatory function. A radiograph is attached showing the tooth structure, though the fracture line itself is best visualized clinically.”

Example 3: Core Buildup (D2950) and Crown

Clinical Situation: Tooth #3 has lost significant coronal structure.

Narrative: “Following the complete removal of a grossly carious lesion and an existing defective restoration on tooth #3, insufficient coronal tooth structure remained to adequately retain a planned full-coverage crown. A core buildup (D2950) was performed using [Material Type, e.g., bonded composite resin] to replace the missing tooth structure and create a solid foundation. This procedure is a necessary prerequisite to ensure the retention and longevity of the crown. Without the buildup, the crown would lack adequate resistance and retention form.”

Example 4: Inlay/Onlay vs. Crown Justification

Clinical Situation: A conservative option is chosen, and you need to justify why a crown isn’t needed.

Narrative: “Examination of tooth #19 revealed a failing DO amalgam with recurrent decay. After caries removal, the remaining tooth structure was sound and substantial, with all cusps intact and strong. To preserve the maximum amount of healthy tooth structure, a conservative onlay restoration was elected over a full crown. This restoration will restore the mesial and distal contours and occlusal table while maintaining the buccal and lingual walls, which are periodontally healthy and free of decay.”

Category 2: Periodontal Narratives

Periodontal claims are heavily scrutinized. The key here is to show a progression of disease and a clear distinction between healthy and diseased sites. Scaling and root planing (SRP) is often denied as “routine prophylaxis.” You must show the presence of disease.

Example 5: Scaling and Root Planing (D4341) – Full Mouth

Clinical Situation: Generalized moderate periodontitis.

Narrative: “This patient presents with a diagnosis of generalized moderate chronic periodontitis. A comprehensive full-mouth periodontal evaluation was performed, revealing generalized 5-7mm probing depths, bleeding upon probing at multiple sites, and moderate subgingival calculus. Radiographs indicate generalized horizontal bone loss of approximately 25-30%. The presence of subgingival biofilm and calculus, coupled with active inflammation and attachment loss, constitutes active periodontal disease. Scaling and root planing (D4341) is required as a non-surgical therapeutic intervention to remove the etiologic agents, arrest disease progression, and facilitate tissue healing. A routine prophylaxis would be inadequate to treat the existing subgingival pathology.”

Example 6: Scaling and Root Planing (D4342) – Per Quadrant

Clinical Situation: Localized periodontitis.

Narrative: “Following a comprehensive periodontal evaluation, the patient was diagnosed with localized moderate chronic periodontitis. Specifically, the mesial and buccal aspects of tooth #19 and the distal aspect of tooth #18 exhibit probing depths of 6mm with purulent exudate and tenacious subgingival calculus. Radiographs show localized vertical bone loss on the mesial of #19. The disease is not generalized. Per quadrant scaling and root planing (D4342) is indicated for these specific quadrants to debride the root surfaces, eliminate the inflammatory irritants, and treat the active disease sites.”

Example 7: Periodontal Maintenance (D4910)

Clinical Situation: Following active periodontal therapy.

Narrative: “The patient has a history of moderate chronic periodontitis and previously completed active Phase I (scaling and root planing) and Phase II (surgery, if applicable) therapy. This appointment is for ongoing periodontal maintenance (D4910). The procedure included a comprehensive review of the patient’s medical history, extraoral and intraoral soft tissue examination, periodontal probing to assess current pocket depths, and reinforcement of home care. Subgingival debridement was performed site-specifically in areas exhibiting continued inflammation or recurrent pocketing. This recall interval and specific therapeutic procedure are necessary to maintain periodontal stability and prevent recurrence of disease in a periodontally susceptible patient.”

Category 3: Oral Surgery Narratives (Extractions)

The difference between a simple extraction (D7140) and a surgical extraction (D7210) often comes down to the narrative. If the tooth is broken down, you likely performed a surgical extraction, and you need to explain why.

Example 8: Surgical Extraction (D7210) – Sectioning Required

Clinical Situation: Tooth #1 is decayed to the gumline.

Narrative: “Tooth #1 was grossly carious, with the clinical crown completely destroyed by decay at or below the level of the gingival margin. Due to the lack of supragingival tooth structure, normal forceps application was impossible. A surgical approach was necessary. A full-thickness flap was reflected to visualize the tooth structure and alveolar bone. The tooth was sectioned and removed in pieces to preserve the surrounding bone. The site was debrided of granulation tissue, and the flap was approximated with sutures.”

Example 9: Surgical Extraction (D7210) – Root Tip

Clinical Situation: Fractured root tip.

Narrative: “During the attempted simple extraction of tooth #14, the mesio-buccal root tip fractured at the apical third. The fragment was non-mobile and encased in bone, making it inaccessible to forceps. A surgical flap was reflected, and buccal bone was osteotomized to gain access to the root tip. The fragment was then surgically delivered. The area was irrigated and closed primarily.”

Example 10: Removal of Impacted Tooth (D7240)

Clinical Situation: Partially bony impacted wisdom tooth.

Narrative: “The patient was referred for evaluation of tooth #17. Clinical and radiographic examination (panoramic radiograph attached) reveals a mesioangular impacted third molar. The tooth is partially covered by soft tissue and bone. The patient reports recurrent episodes of pericoronitis (inflammation and infection around the operculum). To prevent further infectious episodes, damage to the adjacent tooth #18, and cyst formation, surgical extraction is indicated. The procedure will require an incision, elevation of a flap, and removal of overlying bone to allow for tooth delivery and sectioning.”

Category 4: Endodontic Narratives

Narratives here often justify why a more complex (and expensive) procedure like a root canal on a molar is needed, or why retreatment is necessary.

Example 11: Root Canal Therapy (D3330) – Molar

Clinical Situation: Irreversible pulpitis on a molar.

Narrative: “Patient complained of spontaneous, throbbing pain in the upper right quadrant keeping them awake at night. Clinical examination revealed a deep carious lesion on tooth #3. The tooth was tender to percussion. Thermal and electric pulp testing elicited a prolonged, severe painful response, indicating irreversible pulpitis. The radiograph shows decay approximating the pulp chamber. Root canal therapy is indicated to remove the irreversibly damaged and infected pulp tissue, alleviate pain, and retain the tooth as a functional unit of the dental arch.”

Example 12: Root Canal Retreatment (D3346)

Clinical Situation: Failed root canal with apical pathology.

Narrative: “The patient presents for evaluation of tooth #19, which has a history of root canal therapy. The patient is asymptomatic, but a routine radiographic exam reveals a new, circumscribed radiolucency at the apex of the mesial root. There is no evidence of coronal leakage. The diagnosis is asymptomatic apical periodontitis associated with a previously treated tooth, suggesting a failed initial treatment due to missed anatomy or persistent infection. Nonsurgical endodontic retreatment is indicated to re-instrument and disinfect the root canal system to resolve the periapical pathology and retain the tooth.”

Category 5: Prosthodontic Narratives (Dentures and Partials)

Claims for dentures are generally straightforward, but narratives become vital when dealing with immediate dentures, adjustments, or repairs due to tissue changes.

Example 13: Immediate Denture (D5110, D5120)

Clinical Situation: Patient needs extractions but cannot be edentulous.

Narrative: “The patient presents with several periodontally hopeless teeth, specifically #(list teeth), which require extraction. The patient’s occupation and social requirements necessitate that they never appear without teeth. An immediate complete denture (maxillary D5110 / mandibular D5120) is planned. The denture was fabricated pre-surgically based on diagnostic casts and will be inserted immediately following the necessary extractions. This treatment provides hemostasis, protects the surgical sites, and allows the patient to maintain function and appearance during the healing period. The patient understands that relining will be necessary as resorption occurs.”

Example 14: Reline (D5410) – Tissue Changes

Clinical Situation: Loose denture due to bone resorption.

Narrative: “The patient reports that their existing complete mandibular denture has become progressively loose and uncomfortable over the past two years. Clinical examination reveals significant alveolar ridge resorption since the denture was fabricated. The denture base exhibits poor adaptation to the underlying soft tissue, resulting in instability and sore spots during function. A chairside hard reline (D5410) is indicated to re-establish proper adaptation of the denture base to the current ridge morphology, improving stability, retention, and patient comfort.”

Category 6: Narratives for Medical Necessity

Some dental procedures are covered by the medical side of insurance, not just dental. These narratives need to connect the oral condition to a systemic health issue.

Example 15: Treatment for Obstructive Sleep Apnea (D9946 – Oral Appliance)

Clinical Situation: Patient diagnosed with OSA.

Narrative: “This patient has been diagnosed with mild to moderate Obstructive Sleep Apnea (OSA) by a board-certified sleep physician, as documented in the attached sleep study report (AHI = [Value]). The patient is intolerant to CPAP therapy, citing [Reason, e.g., claustrophobia]. An oral appliance therapy (D9946) is being provided to advance the mandible during sleep. This will increase the posterior oropharyngeal airway space by protruding the tongue and soft palate complex, thereby reducing airway collapsibility and treating the diagnosed medical condition. This treatment is provided under a physician’s order.”

Example 16: Full Mouth Reconstruction for Erosive Lesions (GERD)

Clinical Situation: Severe tooth wear from acid reflux.

Narrative: “The patient presents with a primary complaint of shortening of teeth and loss of chewing ability. A thorough medical history reveals a diagnosis of severe Gastroesophageal Reflux Disease (GERD). Intraoral examination reveals generalized, severe enamel erosion with dentinal exposure on the maxillary and mandibular anterior and posterior teeth. The erosion has resulted in a loss of vertical dimension of occlusion (VDO), as confirmed by cephalometric analysis and clinical rest position assessment. The current condition compromises masticatory function and results in significant dentinal hypersensitivity. Full mouth rehabilitation is medically necessary to restore the lost VDO, protect the remaining tooth structure from further acid erosion, and restore functional occlusion.”

Comparative Tables: At-a-Glance Justification

Sometimes, a quick comparison in a table format within your notes can help clarify your clinical decision-making for an auditor. Here are a couple of examples.

Table 1: Crown vs. Filling Justification

 Periodontal Therapy Types

Helpful Lists: Dos and Don’ts of Narrative Writing

To make your narratives more effective, keep these simple rules in mind.

The “Do” List

• Do be specific. Use tooth numbers, surface names (M, D, B, L, O), and measurements (mm).

• Do connect the procedure to a medical outcome. (e.g., “to restore chewing function,” “to eliminate a source of infection”).

• Do mention failed previous treatments if applicable. (e.g., “Patient has history of recurrent decay under previous crowns”).

• Do note patient-specific risk factors. (e.g., “Patient has xerostomia due to medication,” “Patient is a bruxer”).

• Do keep it professional and objective. Stick to the facts.

The “Don’t” List

• Don’t use vague language like “big filling” or “bad cavity.”

• Don’t be emotional. Avoid phrases like “I feel” or “I think.” Instead, use “The diagnosis is” or “The radiograph indicates.”

• Don’t forget to proofread. Typos can undermine your professionalism.

• Don’t include irrelevant patient information (like marital status or job, unless it relates to treatment needs like bruxism from stress).

• Don’t copy-paste the same generic narrative for every patient. It must be individualized.

Quotations from the Experts

“In the insurance world, if it isn’t documented, it didn’t happen. The narrative is your opportunity to document the ‘why’ behind the ‘what.’ It’s the story that the x-ray and the claim form can’t tell on their own.”
— Teresa Duncan, Dental Management Consultant

“I always tell my clients to think of the insurance adjuster as a very intelligent person who knows nothing about dentistry. Your narrative must educate them on the pathology present and guide them to the logical conclusion that your treatment plan is the only viable option for the patient’s health.”
— A wise Dental Biller

Frequently Asked Questions (FAQ)

Q: How long should a dental narrative be?
A: Brevity is key, but don’t sacrifice clarity. A good narrative is usually 3 to 6 sentences. It should be a concise paragraph, not a page-long essay. Get to the point quickly.

Q: Do I need to write a narrative for every single claim?
A: No. Most routine claims (simple fillings, cleanings on healthy patients) are processed automatically. You should focus your narrative writing on procedures that are statistically prone to denial, such as crowns, SRP, surgical extractions, and complex prosthetics.

Q: My claim was denied. What should I do in the appeal narrative?
A: An appeal narrative should be more direct. Start by stating you are appealing the denial for procedure X on date Y. Then, directly address the reason for denial given by the insurance company. For example, if they denied a crown saying a filling would suffice, your appeal should state: “The denial reason states a filling would suffice. However, as documented in the initial narrative and supporting radiograph, the existing carious lesion and prior restoration have undermined the facial and lingual cusps, leaving them unsupported. A filling would not protect these weakened cusps from fracture, leading to certain restorative failure. A crown is the only medically necessary treatment to ensure long-term tooth survival.”

Q: Should I include the patient’s medical history?
A: Only if it directly impacts dental treatment. For example, a history of diabetes impacts periodontal treatment. A history of GERD impacts erosion treatment. A history of bisphosphonate use impacts extraction planning. If it’s not relevant, leave it out.

Additional Resources

To further strengthen your understanding of dental insurance documentation, we highly recommend exploring the resources provided by the American Dental Association (ADA) . Their guide on dental claim submission provides the official standards for coding and documentation.

Visit the ADA Guide on Claim Submission

Conclusion

Mastering the art of the dental narrative is one of the most effective ways to protect your practice’s revenue and advocate for your patients. It transforms a simple claim form into a powerful story of patient care. Remember to keep your narratives factual, specific, and focused on medical necessity. By using the examples in this guide as a foundation, you can create clear, compelling justifications that help insurance companies understand the value of the treatment you provide, leading to fewer denials and more time spent on what matters most: your patients’ smiles.