CurrentAnthemPolicy 01-102

Caries Arresting Medicament — Medicament Application Guidelines

Scope: policy governing when topical caries-arresting medicaments (e.g., silver diamine fluoride) are considered appropriate dental treatment and the clinical contexts under which application may be performed; applies to Anthem dental benefit determinations and providers submitting claims or requests for review.

Policy Summary

PayerAnthem

PolicyCaries Arresting Medicament — Medicament Application Guidelines

Policy CodePolicy 01-102

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument that a caries arresting medicament is being used as conservative treatment for an active, non‑symptomatic carious lesion and that standard restorative treatment is not appropriate or tolerated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Clinical indication bullets listed

D1354, D1355, D1206…Example CDT codes referenced

6Listed supporting references

Coverage Criteria — When Application Is Covered

Indications for caries arresting medicament application

Covered when ALL of the following are met:

Policy Summary

PayerAnthem

PolicyCaries Arresting Medicament — Medicament Application Guidelines

Policy CodePolicy 01-102

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Primary indication: Used only as a conservative treatment for active, non-symptomatic carious lesions.

Patients unable to tolerate standard restorative treatment: Patients unable to withstand standard restorative treatment, including but not limited to frail patients; uncooperative children; patients with physical and/or cognitive disabilities.

Other clinically appropriate scenarios: Patients with numerous lesions that cannot be treated in one visit.

Other clinically appropriate scenarios: Caries which are difficult to treat with traditional restorations.

Other clinically appropriate scenarios: Patients with limited access to dental care.

Billing consideration: Caries arresting medicament may be considered inclusive when submitted in conjunction with other restorative procedures (contract dependent).

Treatment performed primarily for convenience or cosmetic reasons, or services that do not meet generally accepted standards of dental practice, are not appropriate indications and may not be covered under the member's contract. The policy emphasizes that dental services must be in accordance with standards based on credible peer‑reviewed evidence, specialty society recommendations, and the views of recognized practicing dentists to be considered acceptable clinical care.

The plan performs review of caries arresting medicament application to ensure that requested services meet contractual requirements for medical/dental necessity and adherence to accepted standards; a determination that a service is medically or dentally necessary does not by itself guarantee coverage if the member's contract excludes the service.

Use of a caries arresting medicament outside the policy’s described conservative indication — for example when standard restorative treatment is appropriate and feasible — may be considered not medically/dentally necessary per the plan contract. The medicament is intended as a conservative alternative when removal of sound tooth structure is to be avoided.

Document the clinical rationale if caries arresting medicament is chosen instead of standard restorative care (for example: patient frailty, uncooperative behavior, physical or cognitive disability, numerous lesions, difficult‑to‑treat caries, or limited access to care), since use when standard restorative options are suitable can result in denial.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Coverage and Prior Authorization Guidance

Coverage depends on the member's contract. CDT codes listed elsewhere are informational only and do not guarantee coverage. The plan evaluates whether services meet generally accepted standards of dental care and are medically/dentally necessary and may deny services that do not meet those standards or that are not a covered benefit under the member's contract.

Coverage is contract-dependent; confirm member benefits prior to service
CDT/procedure codes are informational and do not guarantee payment
Services that do not meet generally accepted standards of dental care may be denied

Step Therapy

Provider Actions — When to Use

No explicit step therapy requirements are specified for caries arresting medicament application. Use this therapy as a conservative option when standard restorative treatment cannot be performed or tolerated.

No step therapy required — apply when standard restorative care is not possible or tolerated
Appropriate for frail patients, uncooperative children, patients with physical/cognitive disabilities, numerous lesions, lesions difficult to treat with traditional restorations, or limited access to care

Documentation Required

Documentation Requirements

Document clinical justification in the dental record. Specifically, record that the medicament (for example, silver diamine fluoride) is being used to arrest an active, non‑symptomatic carious lesion and why standard restorative treatment cannot be performed or tolerated.

Document that the lesion is active and non‑symptomatic
Document conservative treatment provided and the specific caries arresting medicament applied
Document clinical reasons standard restorative treatment is not appropriate or cannot be completed (e.g., patient frailty, behavioral issues, medical comorbidities, access limitations)

Denial Risk

Denial Conditions / Risk

Denial conditions include services that are not consistent with generally accepted standards of dental care or are not medically/dentally necessary per the member's plan contract.

Services primarily for convenience or cosmetic purposes may be denied
Services more costly than alternative appropriate treatments may be denied
Failure to document clinical necessity or inability to complete standard restorative care may lead to denial

Background — Clinical Context

Caries arresting medicament application is a non‑invasive, topical treatment intended to arrest active, non‑symptomatic carious lesions without mechanical removal of sound tooth structure. One commonly used agent is silver diamine fluoride (SDF).

The policy frames this intervention as a conservative treatment option to be used when standard restorative care cannot be performed or tolerated; it should be applied only for active, non‑symptomatic lesions and within the context of generally accepted standards of dental practice.

Definitions

Definition — Caries arresting medicament application

TermCaries arresting medicament application

DefinitionConservative treatment of an active, non‑symptomatic carious lesion by topical application of a caries‑arresting or inhibiting medicament without mechanical removal of sound tooth structure.

Common agent exampleSilver diamine fluoride (SDF) is a commonly used agent.

Definition — Generally accepted standards of dental practice

DefinitionGenerally accepted standards of dental practice are standards based on credible scientific evidence published in peer‑reviewed dental literature and generally recognized by the practicing dental community.

Supporting sourcesIncludes specialty society recommendations/criteria and the views of recognized dentists practicing in the relevant clinical area.

ScopeStandards apply to services provided by a dentist exercising prudent clinical judgment for evaluation, diagnosis, or treatment and consider type, frequency, extent, effectiveness, and whether service is cosmetic or primarily for convenience.

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
D2991	application of hydroxyapatite regeneration medicament per tooth

OpenPayer

Caries Arresting Medicament — Medicament Application Guidelines

Coverage Criteria — When Application Is Covered

Coding — Informational CDT Codes

Provider Actions, Prior Authorization, and Documentation

Background — Clinical Context

Definitions