Starting Oct. 1, 2020, New York State Medicaid will cover silver diamine fluoride (SDF), a topical caries arresting or inhibiting medicament.
Member eligibility:
- Benefit covers 0 - 20 years of age inclusive.
- For individuals 21 years of age and older, D1354 is only approvable for those individuals identified with a recipient exception code of “RE 81” (TBI Eligible) or “RE 95” (OPWDD/Managed Care Exemption).
Criteria for reimbursement:
- Covers 2 times per tooth within a 12-month period with a total of 4 times per lifetime of the tooth.
- Covers with topical application of fluoride ("D1206" or "D1208") when they are performed on the same date of service if "D1354" is being used to treat caries and "D1206" or "D1208" is being used to prevent caries.
- Covers the application of SDF to 5 teeth on the same date of service with more teeth considered in exceptional circumstances. Documentation supporting necessity must be submitted with the claim.
Providers are required to obtain written consent and fully disclose risks and benefits of silver diamine fluoride use and discuss treatment alternatives where appropriate.
For more information on clinical criteria for the use of SDF, see the New York State Medicaid Update - July 2020.
