Starting Jan. 1, 2025, EmblemHealth will cover silver diamine fluoride (SDF), a topical caries arresting or inhibiting medicament for all Medicaid/HARP members regardless of age.
Clinical criteria for the use of SDF:
- Stabilize non-symptomatic teeth with active carious lesion and no pulpal exposure.
- Moderate-to-high caries risk (e.g., xerostomia, severe early childhood caries).
- Treatment challenged by behavioral or medical management.
- Difficult to treat carious lesions.
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.
- Caries arresting medicament is not reimbursable when used as a base for a final restoration.
Providers are required to obtain written consent and fully disclose risks and benefits of SDF 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 – Nov. 2024.
JP 64624 1/2025