Silver Diamine Fluoride (SDF) reimbursement (D1354)
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Describes DentaQuest's coverage and billing rules for Silver Diamine Fluoride (CDT D1354) as a value-added treatment for eligible Texas Medicaid and CHIP members, effective September 1, 2020.
Silver Diamine Fluoride (SDF) (CDT D1354) is covered as a treatment option effective September 1, 2020.
Benefit limited to 2 applications per tooth per lifetime with minimum 30 days between applications.
SDF is not reimbursed same day as fluoride varnish (D1206) or fluoride (D1208), and not reimbursed on teeth with restorative procedures (D2000 series) in prior 12 months.
Fee established: $14.12 per tooth for code D1354.
SDF must be deemed medically necessary by the Main Dental Home Provider and requires informed consent from the head of household prior to application.
Coverage Criteria for Silver Diamine Fluoride (D1354)
SDF coverage criteria (D1354)
Covered when ALL of the following are met:
ALL of the following
- Member has active cavitated caries lesion(s) in dentition and is a high caries risk member aged 6 months to 6 years (eligible for SDF reimbursement).
- SDF is deemed medically necessary by the Main Dental Home Provider.
- Informed consent from the head of household has been obtained prior to application.
Limitations
- Coverage limited to 2 applications per tooth per lifetime.
- A minimum of 30 days must elapse between SDF application dates on the same tooth.
Exclusions
- SDF applications are not reimbursed on the same day as fluoride varnish (D1206) or fluoride (D1208).
- SDF is not reimbursed on teeth which have had a restorative procedure (D2000 series) in the prior 12 months.
- Providers should submit CDT code D1354 on a claim form for reimbursement; fee is $14.12 per tooth.
Coding, Limits, and Fees
| 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 without mechanical removal of sound tooth structure. |
Billing and Provider Requirements
Billing and provider requirements for SDF (D1354)
Submit CDT code D1354 on a claim form as normal to request reimbursement for Silver Diamine Fluoride (SDF). Do not bill D1354 on the same day as fluoride varnish (D1206) or fluoride (D1208). Do not bill D1354 on teeth that have had a restorative procedure (D2000 series) in the prior 12 months. Obtain informed consent from the head of household prior to application. SDF must be deemed medically necessary by the Main Dental Home Provider.
- Use CDT code D1354: Interim caries arresting medication application.
- Fee: $14.12 per tooth (submit D1354 for reimbursement on claim form).
- Limitations: max 2 applications per tooth per lifetime; minimum 30 days between applications.
Definitions
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