What insurance policy changes affect HCPCS D1354?

There are 11 tracked policy changes affecting HCPCS D1354, including updates from Texas Medicaid, Pennsylvania Medicaid (DHS), Oklahoma SoonerCare. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS D1354?

Payers that have issued tracked updates for HCPCS D1354 include: Texas Medicaid, Pennsylvania Medicaid (DHS), Oklahoma SoonerCare, Nevada Medicaid, Colorado Medicaid, Alaska Medicaid, Missouri Medicaid (MO HealthNet), Maryland Medicaid.

How do I get notified when HCPCS D1354 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS D1354. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for HCPCS D1354?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

D1354 Insurance Policy Changes

HCPCS D1354 is referenced in 11 tracked payer policy changes from Texas Medicaid, Pennsylvania Medicaid (DHS), and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS D1354 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Medium impact
New Limitation for Application of Caries Arresting Medicament for the CSHCN Services Program
Texas Medicaid·Effective Nov 1, 2026
Effective November 1, 2026, TMHP will deny claims for caries arresting medicament application (D1354) when submitted within six months following an anesthesia procedure (D9224) on the same patient. Billing teams must implement system edits to identify and prevent submission of D1354 claims within this six-month window after D9224 claims.
Medium impact
New Limitation for Application of Caries Arresting Medicament for Texas Medicaid
Texas Medicaid·Effective Nov 1, 2026
Effective November 1, 2026, Texas Medicaid (TMHP) will deny claims for caries arresting medicament (D1354) when submitted within six months of a claim containing anesthesia procedure D9224. Billing teams must implement a six-month lookback requirement before processing D1354 claims to avoid denials.
High impact
MAB2026080601
Pennsylvania Medicaid (DHS)·Effective Aug 1, 2026
Pennsylvania Medical Assistance (Medicaid) program is updating its dental fee schedule effective August 1, 2026, adding six new CDT procedure codes (D9224, D9225, D9244, D9245, D9246, D9247) and removing one code (D9248) to align with 2026 HCPCS updates. Billing teams must immediately update systems, fee schedules, and prior authorization logic for enrolled providers serving MA beneficiaries in the Fee-for-Service delivery system.
High impact
Provider Letter 2026-12: Re: D1354 Reimbursement Rate Update
Oklahoma SoonerCare·Effective Aug 1, 2026
Oklahoma Health Care Authority (OHCA) is reducing reimbursement rates for dental code D1354 (interim caries arresting medicament application) effective August 1, 2026. Rates are decreasing from $76.22 to $18.29 for children and from $83.93 to $20.14 for adults—a 76% reduction. Billing teams must update fee schedules and claims processing systems immediately to avoid payment delays and claim denials.
High impact
Attention Provider Type 22 (Dental): Expanded Coverage for Adults 21 Years and Older
Nevada Medicaid·Effective Jul 1, 2026
Effective July 1, 2026, Nevada Medicaid (Provider Type 22 - Dental) is expanding adult dental coverage for members 21+ to include diagnostic, preventative, periodontal, and operative services (fillings and crowns). All newly covered services are subject to a $1,000 per calendar year expenditure limit, with new error code 5751 applying to claims exceeding this threshold. Emergency and palliative care remain unlimited.
High impact
Special Provider Bulletin - Rate Reductions (B2500528 - 09/2025)
Colorado Medicaid·Effective Oct 1, 2025
Colorado Medicaid is implementing rate reductions effective October 1, 2025, rolling back 1.6% fee increases across all professional and institutional claims due to state budget shortfall. Dental services, pediatric behavioral therapy, and some HCBS services face targeted reductions exceeding 1.6%, with dental codes reduced by 15.5%.
High impact
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500530 - 10/2025)
Colorado Medicaid·Effective Oct 1, 2025
Colorado Medicaid is implementing significant changes including a 1.6% rate reduction for all professional services effective October 1, 2025, with additional targeted cuts for dental and pediatric behavioral therapy services. The policy also includes mandatory DRA compliance documentation due November 1, 2025, and transitions for EDI vendors and pharmacy benefit management systems.
Medium impact
Dental Town Hall FAQ
Alaska Medicaid·Effective Mar 3, 2026
Alaska Medicaid published a comprehensive dental FAQ addressing portal compatibility, claim attachments, travel authorizations, and billing procedures. Key updates include clarification on denture travel authorization processes, retroactive billing allowances, and patient notification requirements for services exceeding annual limits.
Medium impact
Updated MO HealthNet Dental Manual & Webinar
Missouri Medicaid (MO HealthNet)·Effective Oct 6, 2025
MO HealthNet has updated their Dental Manual with several coverage changes including new CDT codes D9222 and D9223, expanded oral exam coverage for adults 21+, and Silver Diamine Fluoride coverage for specific populations. Reimbursement rates have been removed from the manual and are now only available on the Fee Schedule.
Medium impact
Provider Letter 2025-11: RE: Differentiation for D1354
Oklahoma SoonerCare·Effective Apr 10, 2025
Oklahoma Medicaid has clarified strict criteria for billing D1354 (caries arresting medicament) - it's only for silver diamine fluoride on active decay when patients can't receive typical restorative care, limited to once every 6 months with maximum 2 treatments per tooth lifetime. High concentration fluoride and preventive treatments should not be billed as D1354.
Low impact
Reimbursement for Dental Code D1354 Clarification
Maryland Medicaid·Identified Jun 20, 2026
Maryland Medicaid has issued a clarification regarding reimbursement for dental code D1354. This policy provides updated guidance on how this specific dental procedure code should be billed and reimbursed under Maryland's Medicaid program.

All billing codes J3590 99213 99214 99212 99202 99203

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New Limitation for Application of Caries Arresting Medicament for the CSHCN Services Program

New Limitation for Application of Caries Arresting Medicament for Texas Medicaid

MAB2026080601

Provider Letter 2026-12: Re: D1354 Reimbursement Rate Update

Attention Provider Type 22 (Dental): Expanded Coverage for Adults 21 Years and Older

Special Provider Bulletin - Rate Reductions (B2500528 - 09/2025)

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500530 - 10/2025)

Dental Town Hall FAQ

Updated MO HealthNet Dental Manual & Webinar

Provider Letter 2025-11: RE: Differentiation for D1354

Reimbursement for Dental Code D1354 Clarification