CurrentAmbetter NevadaPolicy CP.MP.61

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

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Defines medical necessity criteria, place-of-service (in-office vs ASC/hospital) rules, required documentation, exclusions, coding implications, and billing limitations for IV moderate sedation, IV deep sedation, and general anesthesia in dental care for members/enrollees of Centene-affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyIV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

Policy CodePolicy CP.MP.61

Change TypeAnnual reviewadministrative clarifications

Effective Date

Last ReviewAug 24, 2024

Next Review Date

Key ActionSubmit current (<6 months) diagnostic radiographs or intraoral photos, complete treatment plan, ASA classification, history of failed anesthesia/sedation attempts, referring dentist evaluation, and relevant dental/medical diagnoses with ICD-10 codes as part of the medical necessity documentation.

SourceLink

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CurrentAmbetter NevadaPolicy CP.MP.61

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

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Sign up for Ambetter Nevada Policy CP.MP.61 alerts

Get alerted when Policy CP.MP.61 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyIV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

Policy CodePolicy CP.MP.61

Change TypeAnnual reviewadministrative clarifications

Effective Date

Last ReviewAug 24, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Annual review. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.

Changed title to 'IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures' and adopted Envolve Dental Policy criteria.

1One D9222 or D9239 per date of service allowed

4Units before sedation log required

>=7Teeth threshold for extensive pediatric treatment (ASC/hospital)

Coverage Summary

Policy Number CP.MP.61: This policy addresses coverage for IV moderate sedation, IV deep sedation, and general anesthesia for dental procedures. Status: CURRENT. Coverage stance: Covered with criteria — services are medically necessary only when the policy’s general medical necessity criteria and the applicable place-of-service (in-office OR ASC/hospital) criteria are met and required documentation is provided.

Pediatric treatment thresholds

Number of restorative procedures for pediatric members> 4 restorative procedures = 'lengthy and numerous' (qualifies as indication)

Pediatric extensive treatment>= 7 primary teeth requiring restoration, pulpotomy, or extraction = qualifies for ASC/hospital venue

Pediatric limited treatment (in-office)4-6 teeth requiring restoration, pulpotomy, or extraction = may qualify for in-office venue

Medical Necessity — Criteria and Place-of-Service

Overall medical necessity

IV moderate sedation, IV deep sedation, and general anesthesia are medically necessary when ALL of the following general criteria AND the place-of-service-specific criteria are met:

ALL of the following

I.A One or more indications
- Documented extreme anxiety or fear and documentation of failed local anesthesia, inhalation of nitrous oxide, or oral conscious sedation attempts
- Dental and medical records documentation substantiates a physical, cognitive, or developmental disability (including, but not limited to, congenital cardiac defect, cerebral palsy, epilepsy) that would render the patient non-compliant
- Underlying medical conditions are supported by patient records
- Documentation of allergy or sensitivity to local anesthesia
- Lengthy and numerous (more than four) restorative procedures for pediatric member/enrollee> 4 restorative procedures

Coding

CDT codes (dental anesthesia)mixedCovered

D9222	Deep sedation/general anesthesia - first 15 minutes
D9223	Deep sedation/general anesthesia - each subsequent 15-minute increment
D9239	Intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation

CPT anesthesia codes (informational)CPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified

Provider Actions & Billing Rules

Documentation Required

Required pre-operative documentation

Submit current (<6 months) diagnostic radiographs or intraoral photos, a complete treatment plan, ASA classification, history of failed anesthesia/sedation attempts, referring dentist evaluation records, and documentation of relevant dental and medical diagnoses with ICD-10 codes as part of the medical necessity documentation.

Current (<6 months) diagnostic quality pre-operative radiographs or intraoral photographic images if radiographs are not achievable
Complete treatment plan
ASA physical status classification (note: ASA Classes III and IV for members under age eight will not be approved in a dental office setting)
Specific history of failed anesthesia, sedation, or analgesia/anxiolysis attempts
Referring dentist evaluation records
Patient chart and treatment notes documenting all relevant dental and medical diagnoses and ICD-10 codes

Background, Evidence, and Definitions

Background: The policy summarizes professional society guidance (including ADA, AAP, AAPD, ASA, Society for Pediatric Anesthesia, American Society of Dentist Anesthesiologists, and Society for Pediatric Sedation) and defines levels of sedation: anxiolysis/analgesia, oral conscious sedation, IV moderate sedation, IV deep sedation, and general anesthesia. It emphasizes that pediatric patients are at higher risk for adverse outcomes with sedation and that selection of venue and provider must account for ASA class, airway status, comorbidities, and the extent of dental work. The policy directs that qualified anesthesia providers (with PALS skills) and a second PALS-certified observer be present when indicated, and that high-risk or very young pediatric patients be evaluated by a physician or anesthesiologist before scheduling procedures.

Term	Definition
IV Moderate Sedation	Drug-induced depression of consciousness during which patients respond purposefully to verbal commands; no interventions required to maintain airway; spontaneous ventilation adequate.
IV Deep Sedation	Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated stimulation; may require assistance maintaining airway and ventilation.
General Anesthesia	Drug-induced loss of consciousness during which patients are not arousable even by painful stimulation; often require assistance with airway and ventilation; cardiovascular function may be impaired.

Evidence/guideline sources: professional guidance referenced includes the American Dental Association (ADA) Guidelines for Use of Sedation and General Anesthesia by Dentists, American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) sedation guidance, the American Society of Anesthesiologists (ASA) statement on office-based sedation/anesthesia, and guidance or recommendations from the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation.

Revision History

2021-11approval

Policy approved 11/21; title changed to 'IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures' and Envolve Dental Policy criteria adopted; HCPCS D9230 removed; minor rewording without clinical significance.

2022-10administrative edit

Administrative edits 10/22: Annual review and minor wording clarifications (replaced 'any' with 'one or more' in I.A, combined I.C.1 and I.C.2, background restructuring) with no impact to criteria; added CDT disclaimer and updated references.

2023-10administrative edit

Policy Summary

PayerAmbetter Nevada

PolicyIV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

Policy CodePolicy CP.MP.61

Change TypeAnnual reviewadministrative clarifications

Effective Date

Last ReviewAug 24, 2024

Next Review Date

SourceLink

On This Page

Documentation indicates a pediatric member/enrollee has resisted all other conventional behavior management procedures

Documentation indicates a pediatric member/enrollee has history of uncooperative behaviors that may result in the compromised safety of the member/enrollee, provider, or staff

Documented history of relevant social impact conditions

Complex and extensive surgical procedures such as two or more impacted teeth in two or more quadrants, or two or more extractions of permanent teeth per quadrant in at least two quadrants

I.B Contraindications - None of the following

Member/enrollee has predisposing medical and/or physical conditions that would make general anesthesia unsafe
Member/enrollee is cooperative and has minimal dental needs
General anesthesia or moderate or deep sedation is requested for member/enrollee or dentist convenience
Member/enrollee has history of tolerating similar dental procedures without the need for sedation
Member/enrollee has a choice of an alternative option for treatment
Member/enrollee has an allergy to oral sedatives or reversal agents
Parent or guardian objects to the sedation or general anesthesia
There are no covered and approved dental services to be rendered

I.C Required documentation

Current (less than six months) diagnostic quality pre-operative radiographs or intraoral photographic images if radiographs are not achievable or if requested treatment is not visualized< 6 months
Patient chart and treatment notes document conditions supporting medical necessity and all relevant dental and medical diagnoses and/or ICD-10 diagnosis codes
Patient chart and treatment notes document applicable non-clinical and/or relevant social conditions
Complete treatment plan
ASA physical status classification (ASA Classes III and IV for member/enrollees under the age of eight will not be approved for a dental office setting)ASA III/IV restriction for <8 yrs
Specific history of failed anesthesia, sedation, or analgesia/anxiolysis attempts
Referring dentist evaluation records
State-mandated outpatient (OP) form, if applicable

Place-of-service specific criteria: Either II (in-office) OR III (ASC/hospital) must be met

II. In-office (office-based) appropriate venue
- Member/enrollee exhibits moderate or situational anxiety
- Pediatric member/enrollee with limited treatment need (four to six teeth requiring restoration, pulpotomy, or extraction)4-6 teeth
- Pediatric member/enrollee has social impact conditions necessitating completion of all treatment needs during a single visit
- Pediatric member/enrollee under the age of eight with medically necessary dental services and with an ASA I or II classificationASA I or II
- Pediatric member/enrollee under the age of eight with medically necessary dental services and with an uncompromised airwayuncompromised airway
- Member/enrollee requires extraction of two or more impacted teeth in two or more quadrants
- Member/enrollee requires extraction of two or more permanent teeth per quadrant involving two or more quadrants
III. ASC or hospital outpatient appropriate venue
- Member/enrollee has compromising medical comorbidities
- Local factors (e.g., access to care) or state regulations permit treating cases in an ASC that meet in-office approval conditions
- Pediatric member/enrollee with extensive treatment needs (seven or more teeth requiring restoration, pulpotomy, or extraction of primary teeth)>= 7 teeth
- Pediatric member/enrollee with a combination of at least four teeth requiring restoration, pulpotomy, or extraction of primary teeth and the presence of at least one major medical comorbidity (e.g., documented anxiety disorder, uncontrolled asthma, pre-combative or combative behavior)>=4 teeth + major comorbidity
- Pediatric member/enrollee with social impact conditions necessitating completion of all treatment needs during a single visit and in-office IV sedation or general anesthesia is not accessible

Medical necessity and place-of-service determination

Ensure the policy’s general criteria (indications present, no contraindications, and all required documentation) are met AND confirm the appropriate place-of-service criteria (either II — in-office — OR III — ASC/hospital) are satisfied before requesting coverage; facility selection depends on comorbidities and pediatric age/ASA status.

Billing Rule

CDT billing limits

Note CDT billing limitations and documentation requirements when billing for anesthesia/sedation.

D9222 — Deep sedation/general anesthesia - first 15 minutes
D9239 — Intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9223 — Deep sedation/general anesthesia - each subsequent 15-minute increment
D9243 — Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
Limit one D9222 or D9239 per date of service
More than four units of D9223 or D9243 per date of service requires submission of the sedation log (subject to state-specific regulations)

Documentation Required

ASA restriction for office setting

ASA Class III or IV for members under age eight will not be approved for procedures performed in a dental office; consider ambulatory surgical center or hospital outpatient venue for these patients.

Documentation Required

Qualified provider and personnel requirements

Sedation must be administered by a qualified anesthesia provider (e.g., medical anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist, or second oral surgeon) who is PALS-capable and able to rescue a child from apnea, laryngospasm, and airway obstruction. A second PALS-certified observer must be present to assist and monitor, with no other responsibilities during deep sedation or general anesthesia. Document provider qualifications and the presence of the trained observer.

Administrative edits 10/23: Annual review with minor wording clarifications (replaced 'any' with 'one or more' in I.A, combined I.C.1 and I.C.2), background updated with no impact on criteria; references reviewed and external specialist reviewed.

2024-08-24annual reviewLatest

Annual review 08/24: Background updated with no impact on criteria; references reviewed and updated; reviewed by external specialist. Date of last revision 08/24.

Pediatric member/enrollee with social impact conditions necessitating completion of all treatment needs during a single visit in combination with a major medical comorbidity

Pediatric member/enrollee under the age of eight years with medically necessary dental services meeting clinical criteria and with an ASA III or IV classificationASA III or IV

Pediatric member/enrollee under the age of eight years with medically necessary dental services and a compromised or obstructed airwaycompromised airway

Member/enrollee requires extraction of two or more impacted teeth in two or more quadrants in combination with a major medical comorbidity

Member/enrollee requires extraction of two or more permanent teeth per quadrant involving two or more quadrants in combination with a major medical comorbidity