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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialWellpoint Caries Arresting Policy Update | OpenPay…
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    ModifiedWellpointPolicy 01-102

    Caries Arresting Medicament Application

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    This dental clinical policy governs conservative topical application of a caries-arresting or inhibiting medicament to active, non-symptomatic carious lesions without mechanical removal of sound tooth structure. It provides guidance for providers and benefit determination, subject to the member's contract and applicable law.

    Policy Summary
    PayerWellpoint
    PolicyCaries Arresting Medicament Application
    Policy CodePolicy 01-102
    Change TypeEditorial revisionno material change
    Effective Date01/01/2025
    Last ReviewOct 25, 2024
    Next Review DateN/A
    Key ActionUse only for an active, non-symptomatic carious lesion when at least one qualifying patient or treatment circumstance applies.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6Listed clinical criteria or considerations
    7CDT codes listed for informational purposes
    Per toothApplication basis
    Active, non-symptomaticRequired lesion characteristics

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Contract dependentInclusive billing status

    Clinical Coverage Criteria

    Clinical criteria

    Caries arresting medicament application is appropriate when the lesion requirement and at least one qualifying circumstance are met.

    Core and situational criteria

    • Lesion requirement: Use only as a conservative treatment for an active, non-symptomatic carious lesion.Active and non-symptomatic

    • At least one qualifying circumstance

      • Unable to withstand standard restorative treatment: The patient is unable to withstand standard restorative treatment, including frailty, an uncooperative child, or physical and/or cognitive disabilities.
      • Numerous lesions: The patient has numerous lesions that cannot be treated in one visit.
      • Difficult-to-treat caries: The caries are difficult to treat with traditional restorations.
      • Limited access to dental care: The patient has limited access to dental care.

    Inclusive billing consideration

    Billing treatment is subject to the applicable contract.

    Contract-dependent inclusion: Caries arresting medicament may be considered inclusive when submitted in conjunction with other restorative procedures.Contract dependent

    Whether the service is separately covered or inclusive depends on the applicable contract.

    Informational CDT Codes

    CDT codes listed for informational purposesCDT
    D1206Topical application of fluoride varnish
    D1208Topical application of fluoride - excluding varnish
    D1352Preventive resin restoration in a moderate to high caries risk patient - permanent tooth
    D1354Application of caries arresting medicament - per tooth
    D1355Caries preventive medicament application - per tooth
    D2941Interim therapeutic restoration - primary dentition
    D2991Application of hydroxyapatite regeneration medicament - per tooth

    Clinical Background

    Caries-arresting medicament application is a conservative approach for treating active, non-symptomatic carious lesions. The medicament is applied topically on a per-tooth basis without mechanically removing sound tooth structure. The policy describes its use when standard restorative treatment cannot be tolerated, lesions are numerous or difficult to treat with traditional restorations, or the patient has limited access to dental care.

    Policy Summary
    PayerWellpoint
    PolicyCaries Arresting Medicament Application
    Policy CodePolicy 01-102
    Change TypeEditorial revisionno material change
    Effective Date01/01/2025
    Last ReviewOct 25, 2024
    Next Review DateN/A
    Key ActionUse only for an active, non-symptomatic carious lesion when at least one qualifying patient or treatment circumstance applies.
    SourceLink
    On This Page
    Clinical Coverage CriteriaInformational CDT CodesClinical Background