Medicaid coverage for Fluoride Varnish
What is fluoride varnish?
Fluoride varnish is a protective medication that is painted on teeth to help prevent new cavities and help stop cavities that have already started.
Is fluoride varnish safe?
Yes! Fluoride varnish can be used on babies from the time that they have their first tooth (around 6 months of age), and is supported by the American Dental Association.
Who can perform this procedure?
Only the following professionals may perform the procedure after receiving appropriate training and in accordance with the requirements of state law.
* Physician
* Physician assistant
* Registered nurse
* Advanced practice registered nurse
* Licensed practical nurse
* Registered dental hygienist
* Registered dental assistant
How is it put on the teeth?
The varnish is painted on the teeth. It is quick and easy to apply and does not have a bad taste. There is no pain, but your child may cry just because babies and children don’t like having things put in their mouths by other people. Your child’s teeth may look a little bit yellow after the fluoride varnish is painted on, but this color will come off over the next few days.
How often does the fluoride varnish need to applied?
The fluoride coating works best if painted on the teeth 2-4 times per year.
USPSTF (U.S. Preventive Services Task Force) recommendations
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride.
The USPSTF reviewed the evidence for the prevention and management of dental caries in children up to 5 years of age. The review did not cover the evidence for water fluoridation, application of dental sealants, or prenatal counseling. However, based on strong evidence, the Centers for Disease Control and Prevention Task Force on Community Preventive Services has recommended that local water fluoridation be a part of a population-based strategy for the prevention of tooth decay in communities.
Clinical trials that assess the effectiveness of oral fluoride supplementation started before the age of 5 in preventing dental caries have consistently found that fluoride supplementation prevents 32 percent to 81 percent of caries lesions in primary teeth or tooth surfaces. The smallest proportional reductions occurred in studies with the highest background water fluoride level, which is a level that is not currently considered appropriate for supplementation. Since these trials have several limitations, the overall strength of evidence is considered fair by the USPSTF, and these results should be generalized with caution. Although only 2 studies with mixed results have examined the effectiveness of fluoride supplementation on preventing caries in permanent teeth in preschool children, a larger body of evidence supports the effectiveness of fluoride supplementation in school-aged children to prevent caries in permanent teeth.
Coding and Billing requirements
Medicaid covers fluoride treatments, including fluoride varnish, for all beneficiaries under age twenty-one (21).
Providers and billers should check with respective state Medicaid for specific instructions for billing this procedure. For example Ohio and Maryland Medicaid carriers accepts CPT / CDT code *D1203 and *D1206 respectively whereas Florida Medicaid suggests the physicians to submit CPT code *99499 SC. Mississippi Medicaid will reimburse medical providers for an oral health assessment when the following codes are submitted
*D0145 – Oral evaluation for a patient under three years of age and counseling with primary caregiver
*D1206 – Topical fluoride varnish; therapeutic application for moderate to high caries risk patients.
Fluoride varnish application must be provided along with other sick or well child services. It cannot be the sole reason for the visit
Fluoride treatments may be paid twice per fiscal year (July 1-June 30) and must be at least five (5) months apart.
