CurrentEmpire BluecrossPolicy 01-102

Caries Arresting Medicament (Medicament Application) Guidelines

Guidance on use and coverage review of topical caries-arresting medicaments (such as silver diamine fluoride) for conservative treatment of active non‑symptomatic carious lesions; applies to Empire Bluecross dental benefit review and affected providers/members.

Policy Summary

PayerEmpire Bluecross

PolicyCaries Arresting Medicament (Medicament Application) Guidelines

Policy CodePolicy 01-102

Change TypeNo material changes

Effective Date01/01/2024

Next Review DateN/A

Key ActionCheck member contract for coverage and possible prior authorization when billing CDT code D1354 for application of a caries-arresting medicament.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D1354CDT code for medicament application

D1206, D1208Topical fluoride CDT codes

6Clinical criteria bullets

6References cited

Coverage Criteria — When Application Is Considered

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inv-01: Clinical criteria / candidate selection

Covered when ALL of the following are met:

Primary indication: Application is used only as a conservative treatment for active, non‑symptomatic carious lesions (topical application without mechanical removal of sound tooth structure).

Supported by clinical indications and criteria.

Patient factors making medicament appropriate: Patient is frail; unable to withstand standard restorative treatment (including uncooperative children); has numerous lesions that cannot be treated in one visit; has physical and/or cognitive disabilities; has limited access to dental care.

Enumerated patient factors from policy criteria.

Lesion factors: Caries which are difficult to treat with traditional restorations.

Listed as an indication in policy criteria.

Coding/claim context: Application may be considered inclusive when submitted in conjunction with other restorative procedures (contract dependent).

Policy notes inclusion with other restorative procedures may be contract dependent.

Provider Actions — Authorization, Documentation, and Billing

Prior Authorization

Check member contract / possible prior authorization

Check the member's contract and benefits before providing or billing for caries-arresting medicament application. Coverage and prior authorization (PA) requirements vary by contract; services that meet clinical standards may still be non-covered under the member's plan.

Verify member eligibility and benefits at the time of service.
Confirm whether prior authorization is required per the member's dental contract.
Reference billed CDT codes when checking benefits (e.g., D1354, D1355, D1206, D1208, D1352, D2941, D2991).

Billing Rule

Contract / benefit limitation

Benefits are determined by the member's contract and the plan will apply generally accepted standards of dental care when making coverage determinations. A determination that a service is clinically appropriate does not guarantee it is a covered benefit or that the provider will be reimbursed.

Coverage is subject to the member's contract terms and any applicable limitations or exclusions.
Use the member's contract and plan documents as the definitive source for coverage and reimbursement.
Inclusion of a CDT code in this document is informational and does not imply coverage.

Documentation Required

Clinical justification and documentation

Document clinical justification in the patient record showing the application is for an active, non‑symptomatic carious lesion and that treatment aligns with generally accepted standards of dental care. Documentation should support the clinical indication and rationale for choosing a medicament rather than alternative treatments.

Record clinical findings that identify an active, non‑symptomatic carious lesion.
Include rationale that the selected medicament (for example, SDF) is appropriate and consistent with accepted dental practice.
Attach any supporting imaging or notes that demonstrate why less invasive treatment was selected.

Note

Provider action — authorization, documentation, billing (summary)

Provider action: follow payer and contract requirements for authorization, documentation, and billing to reduce risk of denial or non‑payment.

Bill appropriate CDT codes and ensure documentation supports billed services (see codes list).
Be aware that services must be in accordance with generally accepted standards of dental practice to be considered for coverage.
When in doubt, obtain prior authorization or pre-determination to confirm coverage and reduce claim denials.

Background — Policy Context and Treatment Description

Caries arresting medicament application is a conservative, topical treatment intended to arrest active, non‑symptomatic carious lesions without mechanical removal of sound tooth structure. Silver diamine fluoride (SDF) is a commonly used agent. Use is generally considered when clinical circumstances (for example, patient frailty, inability to tolerate restorative treatment, multiple lesions, disability, or limited access to care) make non‑invasive topical management appropriate.

Definitions

Caries arresting medicament application — definition

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

Typical agentSilver diamine fluoride (SDF) is a commonly used caries‑arresting medicament.

Treatment intentUsed to arrest or inhibit progression of carious lesions rather than to restore tooth structure.

Scope of applicationTopical application per lesion/tooth; may be billed using specific CDT codes where applicable (e.g., D1354).

StandardsUse should align with generally accepted standards of dental practice, including peer‑reviewed evidence and specialty society recommendations.