CurrentEmpire BluecrossPolicy 01-102

Caries Arresting Medicament Application

Policy governing topical application of caries-arresting medicaments (e.g., silver diamine fluoride) as a conservative treatment for active, non‑symptomatic carious lesions; applies to providers and claim reviewers determining dental necessity and benefit applicability under the Plan.

Policy Summary

PayerEmpire Bluecross

PolicyCaries Arresting Medicament Application

Policy CodePolicy 01-102

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify member contract benefits and prior authorization requirements for the listed CDT codes before providing treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D1354CDT code for application per tooth

Frail/childrenAppropriate patient contexts

ConservativeTreatment approach

AAPD/ADAReferences

Coverage Criteria

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Primary criteria

Patient contexts: One or more of: frail patients; patients unable to withstand standard restorative treatment (including uncooperative children; patients with physical and/or cognitive disabilities); patients with numerous lesions that cannot be treated in one visit; caries difficult to treat with traditional restorations; patients with limited access to dental care.
Policy lists these specific indications

Medicament examples: Includes use of silver diamine fluoride (SDF) as a common medicament.

Document references SDF as common

Services for caries arresting medicament application may be excluded when they do not meet the Plan's contractual requirements for generally accepted standards of dental care or when the service is not a covered benefit under the member's contract. The Plan reviews these services to confirm that the requested treatment both meets clinical necessity and is a payable benefit under the member's specific contract; a determination that a service is clinically appropriate does not guarantee it is a covered benefit or payable by the dental plan.

Services performed primarily for patient or provider convenience, for cosmetic purposes, or when they are more costly than an available alternative that properly addresses the patient’s condition may be deemed not medically necessary or excluded from coverage under the member’s contract. Inclusion of a procedure in informational coding lists does not by itself guarantee coverage.

Coding

CDT codes (informational)CDT

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
D2941	Interim therapeutic restoration primary dentition

Provider Actions and Billing Guidance

Prior Authorization

Verify benefits / Prior Authorization Required

Provider should verify member contract benefits and prior authorization requirements for the listed CDT codes before providing services. Prior authorization requirements and coverage vary by contract; confirm eligibility, benefit limits, and any required medical necessity documentation with the plan or via the provider portal.

Verify benefits and prior authorization for CDT codes: D1206, D1208, D1352, D1354, D1355, D2941
Confirm member eligibility and any benefit frequency or age limits
Obtain prior authorization when required by the member's contract before rendering services

Documentation Required

Required Clinical Documentation

Provider must document clinical indication of an active, non‑symptomatic carious lesion and rationale for using a conservative topical medicament (e.g., SDF) in the clinical record. Include tooth-specific findings, radiographic evidence if applicable, risk assessment, and alternative treatment options considered.

Document tooth/lesion location and clinical findings
Record rationale for choosing caries arresting medicament instead of operative treatment
Attach radiographs or risk assessment supporting conservative management when available

Denial Risk

Coverage Determined by Contract — May Not Be Covered

Coverage for caries arresting medicament application is determined by the member's contract. The inclusion of procedure codes in this document is informational and does not guarantee coverage or payment. Services that do not meet the Plan's contractual requirements or are not a covered benefit may be denied.

Services not meeting Plan contractual requirements or not a covered benefit may be denied
Confirm whether D1354/D1355 (caries arresting/preventive medicament) are covered under the member's specific plan
If a service is denied as not a covered benefit, billing and appeal rights follow the member's contract terms

Billing Rule

Provider Action

Actionable reminder for providers: confirm prior authorization and document medical necessity before billing. Failure to verify benefits or provide required documentation may result in claim denial or member liability.

Verify benefits, obtain prior authorization if required, and retain documentation in the chart
Bill appropriate CDT code that reflects the service provided and supported by documentation

Background

Caries arresting medicament application is a conservative, topical treatment applied to an active, non‑symptomatic carious lesion with the goal of arresting or inhibiting progression without mechanical removal of sound tooth structure. Silver diamine fluoride (SDF) is a commonly used medicament. This treatment is intended for situations where standard restorative care is contraindicated or impractical — for example, frail patients, uncooperative children, patients with physical or cognitive disabilities, patients with numerous lesions that cannot be treated in one visit, lesions difficult to treat with traditional restorations, or patients with limited access to dental care. Coverage is allowed only when the application meets the policy’s defined clinical criteria and applicable contract provisions.

Definitions

Caries arresting medicament application — definition / concise description

DefinitionConservative 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.

Common medicament exampleSilver diamine fluoride (SDF) is a commonly used caries‑arresting medicament.

Clinical context for useIntended for active, non‑symptomatic lesions where conservative (non‑restorative) management is appropriate.

Treatment principleApplication arrests or inhibits progression of caries without removing healthy tooth structure.

Standards of careMust align with generally accepted standards of dental practice based on credible scientific evidence, specialty society recommendations, and practicing clinicians' views.