Silver Diamine Fluoride (SDF) benefit for Texas Medicaid
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Defines a value-added SDF benefit available to DentaQuest's Texas Medicaid and CHIP members ages 6 months through 6 years, including coding, fee, limits, and consent requirements. Affects participating providers and covered members in the described age range.
No material clinical or coverage changes in this revision.
Coverage & Eligibility
SDF coverage criteria
Coverage and limits for SDF benefit effective September 1, 2020:
Procedure Codes, Limits, and Timing
| D1354 | CDT Code - D1354 |
Documentation, Authorization & Billing Guidance
Prior authorization / documentation requirements
Silver Diamine Fluoride (SDF) must be prescribed by the Main Dentist. Provider must obtain informed consent signed by head of household prior to SDF application.
- Prescription must come from the member's Main Dentist.
- Obtain informed consent signed by the head of household before applying SDF.
Billing restriction — same‑day disallowance with D1206/D1208
SDF application is not allowed on the same day as procedures D1206 or D1208; billing will be denied if submitted for the same date of service.
- Do not bill D1354 on the same day as D1206 or D1208.
- Refer to the Office Reference Manual (ORM) for additional limitations.
Key Definitions
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