D1354 - Caries Medicament
Topical application of caries arresting medicament.
- Procedure Code
- D1354
- Clinical Category
- Preventive
- Primary ICD-10 Justification
- K02.51 (Dental caries on pit and fissure surface limited to enamel)
- Reference Fee & Claim Types
- BOTH
Insurance Verification Benchmarks & Billing Guidelines
Payer policy benchmarks, pre-submission attachment requirements, and denial prevention rules for D1354.
- 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-CM Justification & Crosswalk Mappings for D1354 (6)
Click any ICD-10-CM diagnosis code below to inspect its reverse procedure mappings and differential coding guide.
| 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 |
Frequently Asked Questions — D1354 (Caries Medicament)
Quick answers for dental billers and treatment coordinators submitting claims for D1354.
What ICD-10 diagnosis codes link to dental procedure D1354?▾
Common ICD-10-CM justification codes for CDT D1354 (Caries Medicament) include: K02.51 - Dental caries on pit and fissure surface limited to enamel (Primary); K02.53 - Dental caries on pit and fissure surface penetrating into pulp; K02.61 - Dental caries on smooth surface limited to enamel; K02.62 - Dental caries on smooth surface penetrating into dentin; K02.63 - Dental caries on smooth surface penetrating into pulp; M35.00 - Sjögren syndrome, unspecified.
Can CDT code D1354 be billed to medical insurance?▾
Billing CDT D1354 (Caries Medicament) to medical insurance depends on the underlying clinical necessity and trauma/pathology documentation. Supported claim types across linked diagnoses: BOTH.
What attachments and documentation are required for billing CDT D1354?▾
Required claim attachments for CDT D1354 (Caries Medicament) include: Standard ADA claim form with CDT procedure code and date of service.
What is the insurance frequency limitation for CDT D1354?▾
Standard commercial insurance frequency for D1354: Subject to group/individual contract frequency limitations (none).
What are common insurance denial reasons and appeal tips for CDT D1354?▾
Denial Code CO-119 (Benefit maximum or frequency limitation exceeded for procedure): Overturn appeal strategy - Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria.