CurrentAetnaPolicy 0124

General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services- CPB-0124

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.

Policy Summary

PayerAetna

PolicyGeneral Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services- CPB-0124

Policy CodePolicy 0124

Change TypeClarified (no clinical changes)

Effective DateMay 1, 1996

Next Review DateJan 25, 2024

Key ActionVerify and document physical, intellectual, or medically compromising conditions with appropriate medical documentation when using these as the basis for anesthesia coverage.

SourceLink

POLICY UPDATE CHANGES

Last review recorded on 09/12/2023; no clinical policy statement change indicated in the document.

6Named medical necessity indications

multipleCPT/HCPCS codes listed

1996-05-01Policy effective date

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.

Policy metadata

Policy number0124

Policy title/subjectGeneral anesthesia and monitored anesthesia care for oral and maxillofacial surgery and dental services

Effective date1996-05-01

Last review2023-09-12

Next review2024-01-25

Scope summaryDefines medical necessity criteria for coverage of general anesthesia and monitored anesthesia care (MAC) for oral and maxillofacial surgery and dental services; lists applicable CPT/HCPCS/ADA (CDT) and related codes and notes coverage may apply even when dental/OMS services are excluded from medical benefits if criteria are met.

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

Covered CPT codes (if selection criteria are met)CPTCovered

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.

1–10 of 57

1/6

Covered HCPCS / ADA (CDT-4) codes (if selection criteria are met)HCPCSCovered

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

Documentation Required

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.

Prior Authorization

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.