CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2021 Policy)

Defines medical necessity, monitoring, documentation, and coverage conditions for dental anesthesia modalities (local, regional/trigeminal block, deep sedation/general anesthesia, IV and non‑IV conscious sedation, inhalation nitrous oxide) in conjunction with covered dental or medical benefits and state mandates. Includes clinical indications, contraindications, required documentation and CDT code list for billing reference.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2021 Policy)

Policy CodePolicy 09-201

Change TypeRevised (Annual Review)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit documentation from the oral surgeon/dentist and/or physician to support medical conditions necessitating general anesthesia or conscious sedation, including failed local anesthesia attempts if applicable.

SourceLink

POLICY UPDATE CHANGES

Document revised with annual review dated 12/06/2020 and 11/12/2020 noted in history.

1Local anesthesia separate benefit

1Regional/trigeminal block may be non-covered

1Office anesthesia >60 min requires docs

4Nitrous oxide indications listed