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Dental insurance claim reimbursement: All about narratives

Aug. 11, 2023
This former clinical claim reviewer explains what to include in insurance narratives to make sure your treatment indicates medical necessity and meets the payer’s criteria. A well-written narrative may overturn an adverse determination.

My article on dental insurance claim reimbursement called “Radiographs and narratives for crowns, onlays, core buildups” is about the common radiographic and narrative requirements for crowns, onlays, and restorative foundations. Read on for more on the topic of narratives.

What should be in a narrative

I’ve said before that intraoral photography is useful for crown, onlay, veneer, and core buildup claims, but I highly recommend that the diagnosis and treatment details be documented in a narrative. Technically, a narrative is any written information. This can be a single word, a sentence, or multiple paragraphs about the tooth and treatment. This written information is often submitted within the claim form itself, housed in Box 35, the “remarks” section of the ADA standard claim form. However, this section is character limited.

I suggest submitting the narrative information as an additional attachment or enclosure. When done as an additional enclosure, the whole story pertaining to the condition of the tooth and the treatment can be relayed. You can add supporting photos to the same page as your narrative, drawing attention to what you want a clinical claim review team to see. Without relaying all the pertinent information, medical necessity may not be established with a radiograph alone.

Some offices submit a copy of a checklist as a narrative. I think a checklist is a useful way to document findings while chairside, and it can serve as a reminder of the important specifics to add to clinical progress notes later. I love checklists as part of my workflow, but they are simply not enough for a powerful, unquestionable, impactful narrative. A well-written narrative may have highly valuable information and may overturn an adverse benefit determination. It is worth taking time to elaborate on your checklist findings.

Establishing medical necessity

Pertinent information to establish medical necessity would include decay and decay into dentin, extent of the decay as a percentage of the occlusal table it compromises, amount of remaining tooth structure, symptomatic cracked tooth and your assessment of the tooth for the diagnosis, and recurrent decay. Etiology for an indirect restoration that may not establish medical necessity would be wear, attrition, abrasion, and abfraction—all with or without sensitivity. Insurance carriers popularly have exclusions for these conditions in the absence of dental caries.

When I would do peer-to-peer calls, dentists would say, “But the tooth was sensitive.” When it comes to the medical necessity for an indirect restoration, sensitivity—in the absence of dental decay—does not meet the criteria for most carriers. From an insurance perspective, there are ways to combat sensitivity, so a restoration is not the only viable option.

Therefore, be mindful when restoring worn dentition or lost vertical dimension. While the patient will benefit from treatment, insurance benefits may not be allocated for these services as they are not deemed medically necessary.

Is there decay in the cervical area of abfraction? Has decay started in the areas of wear? If so, document this in your clinical progress notes, and submit them as supporting information for your services in your narrative.

Read more about dental insurance reimbursement …

Clinically optimizing scaling and root planing

Radiographs and narratives for crowns, onlays, core buildups

Cracked tooth specifics

One helpful chairside diagnostic tool for indirect restorative treatment that I commonly used in clinical practice was transillumination. Transillumination was impactful in demonstrating a cracked tooth to a patient. I routinely acquired photos for documentation and added a note in my clinical progress notes. But be aware that many insurance carriers will not accept transillumination findings, photos, or documentation alone as supporting information to establish proof of loss for medical necessity.

An article by Lubisich et al., “Cracked teeth: A review of the literature,” discusses transillumination and its drawbacks. Lubisich declared transillumination as a method that dramatizes all cracks to a point where craze lines may look structural in nature.1 Additionally, there is ample supporting literature to the perspective that not all cracks need treatment, a perspective shared by many payers.

An article by Mamoun et al., “Cracked tooth diagnosis and treatment: An alternative paradigm,” reviews common clinical examples of cracked teeth, including cusp fractures, fractures into furcations, and root fractures. The authors go on to explain a partial fracture is considered restorable and is done to prevent the catastrophic complete fracture, which would be unrestorable with a direct restoration. This article also reports that not all cracks and craze lines indicate a need for full-coverage restorative treatment if not structural in nature.2

So, although a patient may benefit from having a full-coverage restoration as a predictable, long-term, preventive treatment option, dental benefits are allocated only for cases of true medical necessity. The asymptomatic tooth with craze lines and no structural cracks does not meet the criteria for medical necessity, and typically is not benefited due to the craze lines alone. I recommend that you go further and fully test the teeth with cracks. Document your testing to confirm that the tooth does in fact have a symptomatic crack that requires a full-coverage restoration out of necessity.

Scaling and root planing

All the information we’ve discussed so far is related to indirect restorative treatment. I attended a seminar that suggested narratives for scaling and root planing claims (SRP) should list bleeding, loss of connective tissue, and active disease process. This is something I did when submitting claims from my chairside dentistry in private practice; however, after transitioning to the insurance payer market, it was apparent to me that a narrative has little to no impact on claim reimbursement.

Artificial intelligence is being integrated into many payers’ workflows and does not consider narrative information, only the presence of visible, radiographic bone loss that meets the specific insurance provider’s criteria (generally 2 mm).

Scaling in the presence of gingival inflammation

Now, a claim for D4346, D4910, or D4381 is a different story. For scaling in the presence of generalized moderate or severe gingival inflammation, full mouth (D4346), inflammatory markers must be documented. The easiest way to do this is to mark the bleeding sites while probing. If this is not documented in your periodontal charting, you can document the generalized bleeding in your clinical progress notes from the patient’s examination or hygiene treatment.

As a claim reviewer, I was more inclined to recommend acceptance for benefits if bleeding sites were documented in the periodontal charting. Personally, I did not recommend that benefits be denied in cases where the bleeding wasn’t documented in the periodontal chart but was provided in a narrative.

If you receive an adverse determination for your D4346 claim and have generalized bleeding documented in your clinical progress notes, submit a copy of your notes in your appeal. But remember, if there is bleeding and radiographic bone loss (typically more than 2 mm, measured from the CEJ to the crest of bone), the more appropriate code is D4342 or D4341, depending on the number of teeth involved per quadrant. Your D4346 claim may be denied because it’s not the appropriate treatment to address the areas of bone loss. D4346 is done in the absence of bone loss.

Periodontal maintenance

Periodontal maintenance claims (D4910) sent to clinical review may require a current and complete periodontal chart from the date of service to demonstrate that the patient does not have active disease requiring a repeat scaling. Since D4910 includes site-specific scaling, an isolated pocket with bleeding is reasonable; however, if several teeth in each quadrant are demonstrating active disease process that cannot be maintained but require nonsurgical treatment, D4910 may not be allowed. If you receive an adverse determination, a narrative may be helpful to explain that although the patient has reduced periodontium, you feel their periodontal condition is maintainable with D4910, not requiring a repeat scaling.

Localized delivery of antimicrobial agents

D4381 is the code for placement of localized delivery of antimicrobial agents, such as Arestin or Atridox. Each dental payer will have stipulations as to whether placement of these antimicrobial agents is covered under their dental policies—e.g., whether allowable only after a 90-day healing period following SRP, the number of sites allowable per tooth/quadrant/arch/mouth, and if pocket depths in excess of 5 mm or 6 mm are considered. The payer may request to see documentation of the lot number and expiration date.

I suggest submitting a narrative for placement of Arestin or Atridox, stating the date of service and date of scaling. Explicitly state “following the 90-day healing period, for the occasional, residual, nonhealing, 5 mm+ pocket” along with an updated periodontal chart and include the lot number and expiration date. Using the patient’s medical insurance is a different topic.

Author’s note: As always, these tips and tricks are not a guarantee of coverage; they are recommendations based on hours of clinical claim review and time spent with insurance payers. If the services you performed meet their criteria to establish medical necessity, they want to pay you for your dentistry.

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.


  1. Lubisich EB, Hilton TJ, Ferracane J. Cracked teeth: a review of the kiterature. J Esthet Restor Dent. 2010;22(3):158-167. doi:10.1111/j.1708-8240.2010.00330.x
  2. Mamoun JS, Napoletano D. Cracked tooth diagnosis and treatment: an alternative paradigm. Eur J Dent. 2015;9(2):293-303. doi:10.4103/1305-7456.156840
About the Author

Dominique Fufidio, DDS, FAGD

Dominique Fufidio, DDS, FAGD, is newly appointed as the director of specialty services for Apex Dental Partners. She is also the founder of Fufidio Consulting Group, focusing on dental benefits reimbursement coaching through the eyes of a former clinical claim reviewer, private practice owner, and AI cocreator. Dr. Fufidio is a widely published author and speaker. You may reach her at [email protected].

Updated August 11, 2023