D1354 - Caries Medicament
Topical application of caries arresting medicament.
- Procedure Code
- D1354
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- Subject to group/individual contract frequency limitations (none)
Required Claim Attachments & Pre-Submission Checklist
- Standard ADA claim form with CDT procedure code and date of service
Bill When (Allowable Clinical Criteria)
- Benefits are limited to twice per tooth per benefit year.
Restrictions & Clinical Exclusions
- Benefits for more than twice per tooth per benefit year are denied.
- Fees for D1354 on the same date of service as a restoration are not billable to the patient.
- Benefits for restorations placed within 2 months of D1354 are denied.
- Benefits for restorations for altering occlusion, adjusting vertical dimension, replacing tooth structure lost by attrition, erosion, abrasion, abfraction, corrosion, TMD, or for periodontal, orthodontic, or other splinting are denied, unless covered by group contract.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K02.51 | Dental caries on pit and fissure surface limited to enamel | Dental caries | Yes (Primary) | BOTH | interim caries arresting medicament application – per tooth indicated for Dental caries on pit and fissure surface limited to enamel |
| K02.53 | Dental caries on pit and fissure surface penetrating into pulp | Dental caries | Secondary | BOTH | interim caries arresting medicament application – per tooth indicated for Dental caries on pit and fissure surface penetrating into pulp |
| K02.61 | Dental caries on smooth surface limited to enamel | Dental caries | Secondary | BOTH | interim caries arresting medicament application – per tooth indicated for Dental caries on smooth surface limited to enamel |
| K02.62 | Dental caries on smooth surface penetrating into dentin | Dental caries | Secondary | BOTH | interim caries arresting medicament application – per tooth indicated for Dental caries on smooth surface penetrating into dentin |
| K02.63 | Dental caries on smooth surface penetrating into pulp | Dental caries | Secondary | BOTH | interim caries arresting medicament application – per tooth indicated for Dental caries on smooth surface penetrating into pulp |
| M35.00 | Sjögren syndrome, unspecified | Systemic involvement of connective tissue | Secondary | BOTH | interim caries arresting medicament application – per tooth indicated for Sjögren syndrome, unspecified |