Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesAnesthesiologyAnthem dental anesthesia Coverage Policy Update | …
    Ask Trek AI about this page
    CurrentAnthemPolicy 09-201

    Anesthesia for dental procedures — coverage and documentation

    Customize your policy alerts

    Sign up for Anthem Policy 09-201 alerts

    Get alerted when Policy 09-201 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines medical necessity, coverage considerations, monitoring, documentation, and coding guidance for local, regional, inhalation, conscious sedation, and general anesthesia in dental settings for Anthem members. Applies to providers delivering dental anesthesia services and to benefit determinations under dental or medical plans.

    Policy Summary
    PayerAnthem
    PolicyAnesthesia for dental procedures — coverage and documentation
    Policy CodePolicy 09-201
    Change TypeMinor/No material changes
    Effective DateJan 1, 2024
    Last ReviewNov 1, 2023
    Next Review DateJan 1, 2024
    Key ActionSubmit supporting medical/dental documentation when requesting general anesthesia or conscious sedation benefits performed with covered dental services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12CDT codes included

    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.

    4Monitoring elements
    0-21Age guidance referenced
    >60minOffice anesthesia threshold

    Coverage Criteria for Dental Anesthesia

    General anesthesia / conscious sedation — qualifying indications

    Covered when ANY one of the following is met and adequate supporting documentation is provided:

    Anesthesia benefit criteria: a) Member is a child (up to contract-defined age) with complex dental needs requiring extensive procedures (e.g., multiple restorations, pulpal therapy, extractions).N/A

    Medical documentation from dentist/oral surgeon/physician required to support condition and necessity.

    Anesthesia benefit criteria: b) Member has physical, intellectual, or medically compromising conditions making local anesthesia unlikely to succeed and where anesthesia can be expected to produce a superior result (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity).N/A

    Medical documentation from dentist/oral surgeon/physician required to support condition and necessity.

    Anesthesia benefit criteria: c) Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that cannot be postponed.N/A

    Medical documentation from dentist/oral surgeon/physician required to support condition and necessity.

    Anesthesia benefit criteria: d) Local anesthesia is ineffective (e.g., due to acute infection, anatomic variation, allergy) with documented failed attempts.N/A

    Medical documentation from dentist/oral surgeon/physician required to support condition and necessity.

    Anesthesia benefit criteria: e) Member sustained extensive oral-facial/dental trauma where local anesthesia would be ineffective or compromised.N/A

    Medical documentation from dentist/oral surgeon/physician required to support condition and necessity.

    Coverage prerequisite

    Coverage stance

    Coverage prerequisite: Anesthesia services are covered only when: 1) performed in conjunction with underlying services that are covered under the member's dental or medical benefits plan or 2) when coverage is required by state mandate.N/A

    Check the member's dental and medical benefits plan or applicable state mandate to determine coverage eligibility and applicability.

    Local anesthesia is considered inclusive to dental procedures and is not eligible for separate benefit unless the member's specific plan allows separate coverage. Regional and trigeminal division block anesthesia may not be a covered service under the plan.

    Anesthesia services are covered only when performed in conjunction with an underlying service that is covered under the member's dental or medical benefits plan or when coverage is required by a state mandate. If the anesthesia is not linked to a covered underlying service or is not supported by the member's contract or applicable state requirements, the anesthesia is considered not medically necessary and may be denied.

    Coding and Time-Based Considerations

    CDT anesthesia-related codesCDT
    D9210local anesthesia not in conjunction with operative or surgical procedures
    D9211regional block anesthesia
    D9212trigeminal division block anesthesia
    D9215local anesthesia in conjunction with operative or surgical procedures
    D9219evaluation for deep sedation or general anesthesia
    D9222deep sedation/general anesthesia - first 15 minutes
    D9223deep sedation/general anesthesia - each 15 minute increment
    D9230inhalation of nitrous oxide/analgesia, anxiolysis
    D9239intravenous moderate (conscious) sedation/analgesia - first 15 minutes
    D9243intravenous moderate (conscious) sedation/analgesia - each 15 minute increment
    1–10 of 12
    1/2
    Office anesthesia duration — documentation requirement
    RequirementOffice anesthesia exceeding 60 minutes requires written rationale and documentation.
    Required documentation elementsAll associated x‑ray images, progress notes, operative report and a complete anesthesia record indicating start and stop times of incremental drug administration.
    ApplicabilityApplies to any dental or surgical procedure performed in the office when total anesthesia time is > 60 minutes.

    Provider Actions, Documentation & Billing

    Prior Authorization

    Prior authorization: submit clinical documentation for anesthesia benefit

    General anesthesia or conscious sedation benefits may be provided only when performed with covered dental services and the member meets the clinical criteria; submit supporting medical/dental documentation (physician, oral surgeon or dentist) to demonstrate the qualifying condition and necessity for review.

    Billing Rule

    Local anesthesia billed as part of dental procedure (no separate benefit)

    Local anesthesia is considered inclusive to dental procedures and is not eligible for separate reimbursement unless the member's specific plan allows separate coverage.

    Background

    Anesthesia modalities used in dental practice include local, regional (including trigeminal division blocks), inhalation (e.g., nitrous oxide), conscious (moderate) sedation and deep sedation/general anesthesia. More advanced techniques such as intravenous or inhalation agents typically require additional trained personnel, appropriate monitoring, and adherence to safety and pediatric guidelines. Anthem evaluates coverage for these services based on clinical documentation and whether the anesthesia is provided in connection with covered dental or medical services or required by state mandate.

    Definitions

    Child — definition discrepancy
    AAP/AAPD clinical definitionAAP/AAPD define a child as ages 0 to 21.
    Anthem benefit applicationFor benefit purposes Anthem follows contract-defined and state-mandated ages for IV and inhalation anesthesia rather than the AAP/AAPD 0–21 definition.
    Guidance referenceADA recommends use of AAP/AAPD pediatric sedation monitoring guidelines for children 12 years and under in extraordinary situations.
    Medically/Dentally Necessary — definition
    Core definitionMedically/Dentally Necessary means services consistent with the member's diagnosis or condition.
    When considered renderedServices rendered in response to a life‑threatening condition or pain; to treat injury, illness or infection related to the dentition; or to achieve dentition function consistent with community standards.
    Policy Summary
    PayerAnthem
    PolicyAnesthesia for dental procedures — coverage and documentation
    Policy CodePolicy 09-201
    Change TypeMinor/No material changes
    Effective DateJan 1, 2024
    Last ReviewNov 1, 2023
    Next Review DateJan 1, 2024
    Key ActionSubmit supporting medical/dental documentation when requesting general anesthesia or conscious sedation benefits performed with covered dental services.
    SourceLink
    On This Page
    Coverage Criteria for Dental AnesthesiaCoding and Time-Based ConsiderationsProvider Actions, Documentation & BillingBackgroundDefinitions
    Documentation Required

    Documentation: complete anesthesia record with drugs, times, doses, monitoring

    Maintain a complete anesthesia record that documents all drugs administered with names, times and dosages, and continuous physiologic monitoring of oxygenation, ventilation and circulation; include these records in any review.

    • Document drug names, time of administration and dosages (local, IV or inhalation).
    • Continuously monitor and document oxygenation (including pulse oximetry), ventilation (observed respirations/chest movement), and circulation (blood pressure and heart rate pre-, intra-, and post‑op).
    • Include monitoring parameters in the anesthesia record submitted for benefit review.
    Documentation Required

    Staffing & emergency preparedness for IV/inhalation anesthesia

    When IV or inhalation agents are used, additional individuals trained in Basic Life Support for Healthcare Providers must be present and the dentist is responsible for emergency drugs, equipment and protocols; if state-required, maintain current equipment inspection certificate, sedation license and CPR certification.

    • Ensure at least one additional BLS-trained individual is present during use of IV/inhalation anesthetics.
    • Dentist must provide emergency drugs, appropriate equipment and office emergency protocols.
    • Maintain state-required documentation (equipment inspection, sedation license, CPR) when applicable.
    Denial Risk

    Coverage linkage: anesthesia covered only with covered underlying services or state mandate

    Anesthesia services are covered only when performed in conjunction with underlying services that are covered under the member's dental or medical benefits plan or when coverage is required by state mandate; absence of coverage in the member's plan may result in denial.

    • Verify member's dental/medical benefit or applicable state mandate before billing anesthesia alone.
    • If the underlying service is not covered by the member's plan, anesthesia-only claims may be denied.
    Standards of careMust follow generally accepted standards of dental practice (credible peer‑reviewed evidence, specialty society recommendations, and practicing dentist judgment).