Silver Diamine Fluoride (SDF) for dental caries — Coverage Criteria
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Adds coverage and clinical guidance for topical Silver Diamine Fluoride (SDF) as a preventive/caries-arresting benefit for eligible pediatric Medicaid/CHIP members; describes indications, billing, limitations, and informed consent content for providers.
Silver Diamine Fluoride (SDF) is added as an extra benefit effective September 1, 2020 for Texas Medicaid and CHIP members.
Coverage limited to children aged 6 months to 6 years and limited applications per lifetime.
Defines billing code D1354 and fee schedule amount of $14.12.
Clinical and administrative restrictions: not allowed same day as D1206/D1208; not allowed on teeth with D2000 series procedures within prior 12 months; D2000 procedures not allowed for 30 days after D1354.
Coverage Criteria for Silver Diamine Fluoride (SDF)
Covered indications and limits
Covered when ALL of the following are met
Coverage aligned to pediatric risk period
Lesion selection: no clinical signs of pulpal inflammation or spontaneous pain; lesion not encroaching on the pulp (radiographs if possible to assess depth); lesion accessible for brush application; no known silver allergy; no stomatitis or ulcerative gingival conditions
Rubber dam or gingival barrier must be used during application; providers and caregivers should counsel that SDF will blacken demineralized carious tissue
Fee established per policy; follow normal claim submission procedures
Do not apply Silver Diamine Fluoride (SDF, CDT D1354) on the same day as topical fluoride varnish or topical fluoride: not allowed same day as D1206 or D1208. Additionally, SDF is not permitted on teeth that have undergone restorative procedures in the D2000 series within the prior 12 months, and D2000 series restorative procedures must not be performed for 30 days after application of D1354 to allow the SDF treatment effect to complete.
Do not use SDF when there are clinical signs of pulpal inflammation or reports of unsolicited/spontaneous pain, or when carious lesions are encroaching on the pulp. SDF should only be used on lesions that are accessible for brush application and after radiographic assessment when depth is a concern. Do not use SDF for patients with a known silver allergy or where stomatitis or ulcerative gingival conditions are present.
Coding, Limits, and Fee Information
| D1354 | Interim caries arresting medication application - conservative treatment of an active non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure |
| D1206 | Topical fluoride varnish |
| D1208 | Topical application of fluoride (excluding varnish) |
| D2000 series | Restorative procedures (D2000 series restorative procedures) |
| D1354 | Fee per application: $14.12 |
Provider Requirements and Operational Guidance
Medical necessity required from main dental home
D1354 must be deemed medically necessary by the patient’s Main dental Home provider and the determination should accompany billing for the service.
Re-application frequency and lifetime limit
Re-application is recommended every six months until the lesion is restored or arrested or the tooth exfoliates; administration is limited to two lifetime applications.
- Limit: 2 applications per lifetime
- Recommended interval: biannual re-application until resolution or exfoliation
- Minimum separation between applications: 30 days
Claim submission — bill D1354 as usual
Submit procedure code D1354 on the claim form as a normal fee‑for‑service billing item; the fee will be $14.12.
Restrictions with restorative and fluoride procedures
Do not apply D1354 to teeth that have had D2000‑series restorative procedures within the prior 12 months, and do not perform D2000‑series restorative procedures for 30 days after D1354 application; D1354 is also not allowed the same day as D1206 or D1208.
- D1354 not allowed on teeth with D2000 procedures in prior 12 months
- D2000 procedures prohibited for 30 days after D1354
- Not allowed same day as D1206 (fluoride varnish) or D1208 (topical fluoride)
Background
Silver Diamine Fluoride (SDF) is a topical medicament combining silver, ammonia, and fluoride used as a non‑invasive, chairside treatment to arrest active cavitated carious lesions, reduce bacterial activity, promote remineralization, and treat dental hypersensitivity. It is particularly useful as a "no‑needle/no‑drill" alternative for children and patients with behavioral or medical management challenges, high caries risk, difficult‑to‑treat lesions, or limited access to care. Clinically, SDF is applied topically with a brush to accessible cavitated lesions and will turn demineralized carious areas black; healthy tooth structure will not stain. Use of a rubber dam or gingival barrier is required during application.
Definitions and Application Effects
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