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Policy No:  10A

Originally Created: 01/01/2011

Section: Preventive

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Topical Fluoride application of fluoride varnish (D1206)

Topical Fluoride application of fluoride (D1208)

Interim caries arresting medicament application - per tooth (D1354)

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

Policy/criteria

Procedures are in accordance with generally accepted standards of dental practice.

Brush varnish for application of fluoride, use (D1206)

Brush varnish for desensitizing, use (D9910)

Administrative guidelines

Process to contract benefits.

Note: Brush varnish for application of fluoride is usually done on children ages 17 and under.

Codes

CDT - D1000-D1999 - see above

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.