Dental Program Code Activation




TO:      All Dental Providers, Oral surgeons, Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC)


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D1354 – Interim caries arresting medicament application – per tooth


·             Retroactive Effective Date 01/01/2019

·             No Prior Authorization (PA) required

·                Limited to 5 applications per 6 calendar months (if it is applied in January, it can be applied again any time in July)

·             Limited to 4 applications per tooth per lifetime

·             Informed Consent including pictures of SDF staining required

·             No other treatment allowed on the same tooth the same day of service

·             Tooth number must be listed on the claim form

·             Age restriction 0-20


Silver Diamine Fluoride (SDF) is a non-invasive/non-surgical option to hospital treatment to avoid the risk of placing very young children under general anesthesia. Use of SDF in certain cases offers great potential for OR diversion in arresting early caries in-office, followed by restorative treatment if indicated, once the child is mature enough to accept such treatment.

As a reminder, the Provider Billing Manual is updated each quarter (January, April, July, and October), and these changes will be reflected in Chapter 13 of the July 2019 Provider Billing Manual.

You may contact the Dental Program with questions by emailing: