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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellpoint Caries Medicament Coverage | OpenPayer
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    CurrentWellpointPolicy 01-102

    Caries Arresting Medicament Application

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    This policy governs the clinical criteria and coding guidance for topical application of a caries-arresting or inhibiting medicament on a per-tooth basis for active, non-symptomatic carious lesions. It applies to providers submitting dental services, subject to the member's applicable contract benefits.

    Policy Summary
    PayerWellpoint
    PolicyCaries Arresting Medicament Application
    Policy CodePolicy 01-102
    Change TypeAdministrative/editorial revisionno material clinical or coverage change
    Effective Date01/01/2026
    Last ReviewSep 26, 2025
    Next Review DateN/A
    Key ActionUse the medicament only as conservative treatment for an active, non-symptomatic carious lesion, applying it topically on a per-tooth basis without mechanically removing sound tooth structure.
    SourceLink
    POLICY UPDATE CHANGES

    The 09/26/2025 revision made minor editorial refinements to the description, clinical indications, and references while leaving the policy intent unchanged.

    D1354Primary CDT code
    5Qualifying clinical circumstances
    Active, non-symptomaticRequired lesion characteristics
    Per toothApplication basis
    Policy Summary
    PayerWellpoint
    PolicyCaries Arresting Medicament Application
    Policy CodePolicy 01-102
    Change TypeAdministrative/editorial revisionno material clinical or coverage change
    Effective Date01/01/2026
    Last ReviewSep 26, 2025
    Next Review DateN/A
    Key ActionUse the medicament only as conservative treatment for an active, non-symptomatic carious lesion, applying it topically on a per-tooth basis without mechanically removing sound tooth structure.
    SourceLink
    On This Page
    Clinical Indications and CriteriaInformational CDT CodesClinical Indication and Billing ConsiderationsPolicy BackgroundCaries Arresting Medicament Application

    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

    Clinical Indications and Criteria

    Clinical indications and criteria

    Caries arresting medicament application is appropriate when the mandatory lesion and treatment requirements are met and at least one qualifying clinical circumstance applies.

    Core and qualifying circumstances

    • Core treatment indication: Use only as conservative treatment for an active, non-symptomatic carious lesion by topical application of a caries-arresting or inhibiting medicament.Active and non-symptomatic

    • At least one qualifying clinical circumstance

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

    Informational CDT Codes

    CDT codes included for informational purposesCDT
    D1206Topical application of fluoride varnish
    D1208Topical application of fluoride - excluding varnish
    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 Indication and Billing Considerations

    Denial Risk

    Does Not Meet Clinical Indication

    Does not meet clinical indication when the treatment is not a conservative treatment of an active, non-symptomatic carious lesion or involves mechanical removal of sound tooth structure.

    • Use only for topical application of a caries-arresting or inhibiting medicament on an active, non-symptomatic carious lesion.
    • Do not report as meeting this indication when sound tooth structure is mechanically removed.

    Policy Background

    A caries-arresting or inhibiting medicament is applied topically to an active, non-symptomatic carious lesion on a per-tooth basis, without mechanically removing sound tooth structure. This conservative approach may be useful for patients who cannot tolerate standard restorative treatment, have numerous or difficult-to-treat lesions, or have limited access to dental care.

    Caries Arresting Medicament Application

    Caries Arresting Medicament Application
    Treatment typeConservative treatment using a caries-arresting or inhibiting medicament
    ApplicationTopical application on a per-tooth basis
    Indicated lesionActive, non-symptomatic carious lesion
    Tooth structureNo mechanical removal of sound tooth structure