CurrentBlue Cross Blue Shield - WisconsinPolicy 01-102

Caries Arresting Medicament Application

Covers topical application of caries‑arresting or inhibiting medicaments to active, non‑symptomatic carious lesions without mechanical removal of sound tooth structure; applies to dental providers treating BCBS Wisconsin members per contract benefits.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyCaries Arresting Medicament Application

Policy CodePolicy 01-102

Change TypeNo material change

Effective Date

Next Review DateJan 1, 2025

Key ActionVerify member contract benefits and submit using the applicable CDT procedure codes (for example D1354) before providing or billing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Clinical indications bullets

5CDT codes referenced

8References cited

01-102Document

Coverage Criteria

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

From policy criteria item 1

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

From policy criteria item 2

Other appropriate scenarios: Patients with numerous lesions that cannot be treated in one visit; Caries which are difficult to treat with traditional restorations; Patients with limited access to dental care.

From policy criteria items 3–5

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

From policy criteria item 6

Coding

Informational CDT procedure codesmixed

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.

Additional referenced CDT codesmixed

D2941	Interim therapeutic restoration - primary dentition
D2991	application of hydroxyapatite regeneration medicament - per tooth

Provider Actions and Billing Requirements

Prior Authorization

Prior Authorization — Verify Contract

Verify the member's contract for any prior authorization requirements before providing services.

Confirm prior authorization requirements with Blue Cross Blue Shield - Wisconsin.
Prior authorization requirements may vary by plan and service date.

Documentation Required

Provider Action — Documentation and Submission

Providers should take the following actions to support claim processing and payment.

Obtain and document medical necessity and supporting clinical records relevant to the procedure.
Submit all required documentation when requested by the payer to avoid delays or denials.

Billing Rule

Coding and Benefit Verification

Use CDT procedure codes when submitting dental claims and verify member contract benefits for coverage and reimbursement.

Submit claims using the appropriate CDT codes (examples below).
Verify allowable reimbursement and any member cost share prior to rendering services.

Denial Risk

Contract / Benefit‑Based Denial Risk

Coverage and reimbursement are determined by the member's contract benefits in effect at the time of service. Lack of applicable benefit may result in denial or patient liability.

Denials may be issued if services are not covered under the member's plan or if submission/billing requirements are not met.
Always confirm coverage, eligibility, and benefit limits for the date of service.

Background

Topical caries‑arresting medicaments are applied on a per‑tooth basis to treat active, non‑symptomatic carious lesions without mechanically removing sound tooth structure. They are a conservative treatment option used when standard restorative care is not appropriate or feasible (for example, for frail patients, uncooperative children, patients with physical or cognitive disabilities, those with numerous lesions that cannot be treated in a single visit, or patients with limited access to dental care). Common examples referenced in clinical guidance include silver diamine fluoride and fluoride varnish.

Definitions

Caries arresting medicament application — definition as key/value(s).

DefinitionTopical application of a caries‑arresting or inhibiting medicament on a per‑tooth basis without mechanical removal of sound tooth structure to treat active, non‑symptomatic carious lesions.

Treatment intentConservative, non‑restorative management intended to arrest or inhibit progression of active, non‑symptomatic caries.

Application scopeApplied on a per‑tooth basis; no mechanical removal of sound tooth structure is performed.

Typical use casesUsed for patients who cannot tolerate standard restorative care, have numerous lesions, or limited access to dental care (conservative alternative).