CurrentAnthemPolicy N/A

Caries Arresting Medicament Application Guidelines

Guidance on clinical indications and application of caries arresting medicaments (notably silver diamine fluoride) as a conservative treatment for active, non-symptomatic carious lesions and related dental review standards. Includes criteria for patient selection and example billing codes provided for informational purposes only.

Policy Summary

PayerAnthem

PolicyCaries Arresting Medicament Application Guidelines

Policy CodePolicy N/A

Change TypeAnnual revision noted through 10/21/2022

Effective Date

Next Review Date

Key ActionDocument that the lesion is active and non-symptomatic, that the patient meets one or more listed indications (e.g., frail, unable to tolerate restoration, uncooperative child, numerous lesions, difficult-to-treat caries, limited access), and that treatment aligns with generally accepted dental practice.

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POLICY UPDATE CHANGES

Document revised with annual revisions noted through 10/21/2022 and last review date 01/01/2023.

7Clinical Indication Scenarios Listed

6CDT Codes Listed

Policy overview

Policy subject: Caries Arresting Medicament Application (e.g., Silver Diamine Fluoride). Payer: Anthem. Policy: Caries Arresting Medicament Application Guidelines.

Scope: This guidance covers clinical indications and application of caries arresting medicaments (for example, silver diamine fluoride) as a conservative, topical treatment to arrest active, non-symptomatic carious lesions without mechanical removal of sound tooth structure. It is intended to guide dental necessity review consistent with contract requirements and generally accepted standards of dental practice, and includes informational CDT procedure codes.

Indications and clinical criteria

Indications for Caries Arresting Medicament Application

Apply caries arresting medicament when ALL of the following framework conditions are met and patient fits one or more specific clinical indications:

ALL of the following

Lesion is active and non-symptomatic
Treatment is conservative and topical without mechanical removal of sound tooth structure
Decision aligns with generally accepted standards of dental practice (scientific evidence, specialty recommendations, expert practice views)
Patient clinical scenarios eligible (ONE or more)
- Frail patients
- Patients unable to withstand standard restorative treatment
  Including but not limited to: uncooperative children; patients with physical and/or cognitive disabilities
- Uncooperative children
- Patients with physical and/or cognitive disabilities
- Patients with numerous lesions that cannot be treated in one visit
- Caries that are difficult to treat with traditional restorations
- Patients with limited access to dental care

Definitions

Caries arresting medicament applicationConservative treatment of an active, non-symptomatic carious lesion by topical application of a medicament without mechanical removal of sound tooth structure.

Generally accepted standards of dental practiceStandards based on peer-reviewed evidence, specialty society recommendations, views of recognized dentists, and other credible sources.

Documentation & billing guidance for providers

Documentation Required

Clinical indication documentation

Document that the lesion is active and non-symptomatic, that the patient scenario meets one or more listed indications (for example: frail patients; patients unable to withstand standard restorative treatment including uncooperative children and patients with physical and/or cognitive disabilities; patients with numerous lesions that cannot be treated in one visit; caries difficult to treat with traditional restorations; patients with limited access to dental care), and that the chosen treatment aligns with generally accepted standards of dental practice.

Frail patients
Patients unable to withstand standard restorative treatment (including uncooperative children; patients with physical and/or cognitive disabilities)
Patients with numerous lesions that cannot be treated in one visit
Caries difficult to treat with traditional restorations
Patients with limited access to dental care

Billing Rule

Code use informational only

The listed CDT procedure codes are provided for informational purposes only; their inclusion does not guarantee coverage or provider reimbursement. Verify the member's contract benefits in effect at the time of service to determine coverage or non-coverage.

D1206
D1208
D1352
D1354
D1355
D2941

Relevant procedure and diagnosis codes (informational)

CDT codes (informational list)mixed

D1206	Topical application of fluoride varnish
D1208	Topical application of fluoride excluding varnish
D1352	Preventive resin restoration in a moderate to high caries risk patient permanent tooth
D1354	Application of caries arresting medicament per tooth
D1355	Caries preventive medicament application per tooth
D2941	Interim therapeutic restoration primary dentition

ICD-10-CM Diagnoses (referenced)ICD-10

No codes listed

Supporting evidence and guidelines

Supporting professional guidance cited by the policy includes the American Academy of Pediatric Dentistry position on use of silver diamine fluoride (AAPD 2017, revised 2018) and the American Dental Association evidence-based clinical practice guideline on nonrestorative treatments for carious lesions (ADA October 2018).

Clinical background

Caries arresting medicament application is defined as a conservative, topical treatment of an active, non-symptomatic carious lesion by application of a caries-arresting or inhibiting medicament (one common example is silver diamine fluoride) without mechanical removal of sound tooth structure.

Intended use: This guidance is for dental necessity review to determine whether application meets contract and generally accepted standards of dental practice. It is to be used when the clinician documents that the lesion is active and non-symptomatic and that the patient fits one or more eligible clinical scenarios (for example, frail patients; patients unable to withstand standard restorative treatment including uncooperative children and those with physical or cognitive disabilities; patients with numerous lesions that cannot be treated in one visit; caries difficult to treat with traditional restorations; or patients with limited access to dental care).

The policy notes that review is performed due to contractual requirements that benefits meet generally accepted standards of dental care and that inclusion of procedure codes is informational only; verification of member contract benefits is necessary to determine coverage.

Document revisions

04/22/2020publication

Initial publication (Initial).

12/04/2020revision

Annual revision (Committee).

10/06/2021revision

Annual revision (Committee).

10/21/2022revision

Annual revision (Committee).

01/01/2023reviewLatest

Document revised with annual revisions noted through 10/21/2022 and last review date 01/01/2023.

Policy Summary

PayerAnthem

PolicyCaries Arresting Medicament Application Guidelines

Policy CodePolicy N/A

Change TypeAnnual revision noted through 10/21/2022

Effective Date

Next Review Date

SourceLink

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