It has been two years since the U.S. Preventive Services Task Force (USPSTF) recommended (Grade B) that fluoride varnish application be provided in the primary care setting to reduce the risk of dental caries. The USPSTF recommends fluoride varnish be applied two to four times a year for all children ages 6 months through 5 years (to the 6th birthday). Under the Affordable Care Act, this preventive service should be provided to all children with no cost-sharing.
When submitting claims for payment, CPT code 99188 is used to report the application of topical fluoride varnish by a physician or other qualified health professional. In a combined effort by the Section on Oral Health and the Private Payer Advocacy Advisory Committee, the Academy has sent letters to national and large regional health plans urging appropriate payment of CPT code 99188.
Presently, Medicaid programs in 49 states are paying for this service. Also, the largest national carriers are covering fluoride varnish application by physicians as a separately paid service, including Anthem, Aetna and UnitedHealthcare (UHC). Depending on the particular health plan, there may be coverage variations. For example, fluoride varnish application is covered from 0 through age 6 years, paid at 100% of the contracted rate by UHC, whereas Aetna’s coverage includes children ages 6 months through 11 years. Anthem reported having no age restrictions.
