FLUORIDE VARNISH CPT D1206 AND VALID DX

D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

CRITERIA:

• Patient must be – age 6 months to 21 years

• Recommend the fluoride varnish be applied at the time of a well child visit /

Health Tracks screening

• Allow a maximum of two (2) applications per year, per patient

• Only the following professionals may perform the procedure after receiving appropriate board approved training

a. Physicians

b. Nurse Practitioners

c. Physician Assistants

d. Registered Nurses and Licensed Practical Nurses under the direct supervision of a physician (claim must be submitted with under the physician’s PIN)

e. Registered Dental Hygienist or Registered Dental Assistant under the direct or general supervision of a licensed dentist.

NOTE: This service is currently covered when rendered by a dentist.

COVERED DIAGNOSIS:

V07.31 Prophylactic fluoride administration

►This guideline supersedes previous Fluoride Varnish guideline(s).