New York State Medicaid reimburses for topical fluoride treatment when professionally administered in accordance with established standards. This benefit is limited to gel, foam, and varnish.
Effective July 1, 2021, EmblemHealth Medicaid and Health and Recovery Plan (HARP) member coverage has been expanded for the following Current Procedural Terminology (CPT) codes:
- "D1206" Topical application of Fluoride Varnish is reimbursable for members between six months and 20 years of age (inclusive) up to four times per year. However, there must be an interval of not less than three months between any type of fluoride treatment to qualify for reimbursement.
- "D1208" Topical application of fluoride excluding varnish is reimbursable once per six-month period for members between one and 20 years of age (inclusive).
- For members 21 years of age and older, both "D1208" and "D1206" are only approvable for those members identified with a Recipient Exception (RE) code of "81" (Traumatic Brain Injury Eligible) or "95" (Office for People With Developmental Disabilities (OPWDD)/Managed Care Exemption), or in cases where salivary gland function has been compromised as a result of surgery, radiation, or disease.
Note: This expansion does not apply to non-dental practitioner application of fluoride varnish in a primary care setting using CPT code "99188".
For more information, refer to the June 2021 Medicaid Update - Fluoride Varnish Application Expansion for Dental Providers.
