General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services- CPB-0124
Customize your policy alerts
Sign up for Aetna Policy 0124 alerts
Get alerted when Policy 0124 changes without checking for updates manually.
Monitor payer policy activity
Policy defines medical necessity criteria for coverage of general anesthesia and monitored anesthesia care (MAC) for oral and maxillofacial surgery and dental services, including when anesthesia is covered even if the dental/OMS service is excluded from medical benefits. Lists applicable CPT/HCPCS/ADA (CDT) and ICD-10 codes related to covered procedures.
Last review recorded on 09/12/2023; no clinical policy statement change indicated in the document.
Coverage Summary
Overview: This policy (Number: 0124) defines medical necessity criteria for coverage of general anesthesia and monitored anesthesia care (MAC) for oral and maxillofacial surgery and dental services. Effective date: 1996-05-01. Last review: 2023-09-12.
Medical Necessity Criteria
Medical Necessity - Covered when ANY of the following are met
Aetna considers general anesthesia and MAC medically necessary for dental or OMS services if any of the following criteria is met:
- Child with complex dental needs: The member is a child, up to and including 12 years old, with a dental condition that requires repairs of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions or any combinations of these or other dental procedures).
- Physical, intellectual, or medically compromising conditions: Members who exhibit physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and which, under anesthesia, can be expected to produce a superior result.
Conditions include but are not limited to intellectual disability, cerebral palsy, epilepsy, cardiac problems and hyperactivity (verified by appropriate medical documentation).
- Extremely uncooperative or anxious members: Members who are extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity.
- Local anesthesia ineffective: Members for whom local anesthesia is ineffective (such as due to acute infection, anatomic variations or allergy).
- Extensive oral-facial or dental trauma: Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised.
- Bony impacted wisdom teeth: Members with bony impacted wisdom teeth.
Coding
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00171 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00172 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00173 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00174 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00175 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00176 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00190 | Anesthesia for procedures on facial bones or skull. |
| 00191 | Anesthesia for procedures on facial bones or skull. |
| 00192 | Anesthesia for procedures on facial bones or skull. |
| D9248 | Nonintravenous conscious sedation. |
| D9210 | Local anesthesia not in conjunction with operative or surgical procedures. |
| D9211 | Regional block anesthesia. |
| D9212 | Trigeminal division block anesthesia. |
| D9215 | Local anesthesia in conjunction with operative or surgical procedures. |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room). |
Provider Actions & Requirements
Medical documentation for medically compromising conditions
Verify and document physical, intellectual, or medically compromising conditions (e.g., intellectual disability, cerebral palsy, epilepsy, cardiac problems, hyperactivity) with appropriate medical documentation when using these as the basis for anesthesia coverage.
Coverage contingent on underlying service benefit
Anesthesia coverage is available only in connection with underlying services that are covered under the medical benefits plan unless the policy's medical necessity criteria are met to cover anesthesia in conjunction with dental/OMS services excluded from medical benefits; check member benefits for coverage determination.
Background and Guideline Context
Background: The policy references guidelines from the American Academy of Pediatric Dentistry (AAPD) regarding indications for deep sedation and general anesthesia in pediatric dental patients and other sources (e.g., French National Authority for Health). The guidance identifies children and patients with certain physical, mental, or medically compromising conditions, those for whom local anesthesia is ineffective, patients with extensive trauma, and extremely uncooperative or anxious patients as potential indications for deep sedation or general anesthesia. The French guidance further notes that local anesthesia should be preferred when possible and that patients undergoing general anesthesia should have a pre-anesthesia consultation, be informed of potential risks, and provide informed consent.
Revision History
Policy effective date as listed in the document.
Last review recorded on 09/12/2023; no clinical policy statement change indicated in the document.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.