CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

Defines medical necessity, documentation, monitoring, and coverage considerations for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation (nitrous oxide) in dental settings. Applies to Anthem commercial/dental plans and notes state/contract variations.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeAnnual review (clarified)

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionObtain and submit medical documentation from the oral surgeon/dentist and/or physician supporting the condition(s) that necessitate general anesthesia or conscious sedation.

SourceLink

POLICY UPDATE CHANGES

Annual review performed 12/06/2020 with updates reflected in policy document.

1Local anesthesia separate benefit

ConditionalRegional/trigeminal block coverage

ConditionalDeep sedation/general anesthesia coverage

ConditionalNitrous oxide coverage

Scope: Dental anesthesia and sedation services — defines medical necessity, documentation, monitoring, and coverage considerations for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation (nitrous oxide) in dental settings. (Policy #: 09-201; Publish/Effective Date: 01/01/2021; Last Review: 12/06/2020.)

Subject: Dental anesthesia and sedation services — applies to Anthem commercial/dental plans; coverage depends on the member's contract, plan benefits and any applicable state mandates.

High-level note: Coverage of anesthesia services is contingent upon the member's contract and state mandates; a determination that a service is medically/dentally necessary does not guarantee it is a covered benefit under the dental plan.

Key thresholds and applicability

Office anesthesia duration> 60 minutes requires written rationale/documentation

Applies toAnthem commercial/dental plans; state/contract variations may apply

Time of general anesthesia beginsWhen dentist starts administering sedative agent and non-invasive monitoring protocol

Documentation requirementMedical documentation required from oral surgeon/dentist and/or physician for general anesthesia

Medical Necessity Criteria

General Medical Necessity

Anesthesia services are considered medically/dentally necessary when ALL of the following are met:

ALL of the following

Service is consistent with the member's diagnosis or condition
Service is in response to a life-threatening condition or pain
Service treats an injury, illness or infection related to the dentition
Service is to achieve a level of function consistent with prevailing community standards for the diagnosis or condition

Local Anesthesia

Coverage position:

Local anesthesia is considered inclusive with all dental procedures and is not eligible for a separate benefit

Separate billing for local anesthesia may be denied per policy

ref':

Regional and Trigeminal Division Block Anesthesia

Coverage position:

Regional and trigeminal block anesthesia may not be a covered service

Deep Sedation / General Anesthesia / IV Moderate (Conscious) Sedation / Non-IV Conscious Sedation

These procedures may be covered when performed in conjunction with covered dental services and medical necessity documentation supports use. Coverage requires meeting at least ONE of the member criteria and all operational requirements.

ONE of

Member is a child, up to the age defined by contract, with a dental condition requiring complex repairs (e.g., multiple restorations, pulpal therapy, extractions, or combinations)
Member has physical, intellectual, or medically compromising conditions for which treatment under local anesthesia cannot be expected to provide a successful result; conditions must be supported by medical documentation (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity)
Requires medical documentation from physician/oral surgeon/dentist
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs where postponement would likely result in oral pain, infection, tooth loss, or increased morbidity

Inhalation of Nitrous Oxide / Analgesia

Coverage position:

Inhalation nitrous oxide procedures may be covered when appropriate in conjunction with covered dental services

Indications include ONE of

Ineffective local anesthesia administration
Treatment of dental anxiety
Special needs patients
Individuals who are uncooperative or behaviorally challenged

Contraindications include ONE of

Monitoring and Documentation Requirements

Anesthesia monitoring/documentation must meet ALL of the following:

A dentist or appropriately trained individual must remain in the operatory during active dental treatment to continuously monitor the patient's vital signs until discharge criteria to recovery area are met

The individual must be familiar with monitoring techniques and equipment

Monitoring must include observation of proper oxygenation (color of mucosa/skin and oxygen saturation by pulse oximetry) continuously

Ventilation: chest movement must be continually observed; respirations must be verified and documented by trained personnel

Circulation: blood pressure and heart rate must be evaluated pre-operatively, intra-operatively and post-operatively and documented

An appropriate, complete anesthesia record must be maintained including names of all drugs administered, time and dosages, and all physiological parameters with start and stop times

Provider Actions & Billing Impact

Prior Authorization

Potential utilization review for anesthesia services

Plan may perform utilization review of anesthesia services; providers should verify whether prior authorization or review is required by the member's dental/medical plan, contract provisions, or applicable state mandates.

Documentation Required

Support medical necessity for general anesthesia or conscious sedation

Obtain and submit medical documentation from the oral surgeon, dentist and/or physician that supports the medical conditions or reasons necessitating general anesthesia or conscious sedation when coverage is sought.

Documentation Required

Maintain complete anesthesia record

Maintain a complete anesthesia record documenting the names of all drugs administered, times and dosages, start and stop times, and all monitored physiological parameters including oxygenation, ventilation and circulation.

Documentation Required

Document failed local anesthesia attempts

When coverage is requested because local anesthesia was ineffective, document failed attempts and the reasons (for example, acute infection, anatomic variation, or allergy) and submit this documentation for review.

Documentation Required

Justify anesthesia duration >60 minutes

Provide written rationale and documentation explaining the medical necessity when office anesthesia exceeds 60 minutes for a dental or surgical procedure.

Documentation Required

Monitoring and staff credential requirements

Ensure appropriately trained personnel remain to continuously monitor the patient during active treatment, confirm staff have required BLS/CPR certifications, and, if required by the State, maintain sedation licenses and current equipment inspection certificates.

Denial Risk

Separate billing for local anesthesia

Local anesthesia billed separately (codes listed below) may be denied because local anesthesia is considered inclusive with dental procedures and is not eligible for a separate benefit.

D9210
D9215

Background & Evidence

Background: This policy outlines medical necessity standards and generally accepted dental practice for the use of local anesthesia, regional and trigeminal division block anesthesia, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation of nitrous oxide in dental settings. It explains that the plan reviews anesthesia services to ensure benefits meet contractual requirements and generally accepted standards of dental care, and that a finding of medical necessity does not by itself ensure a payable benefit.

Coverage depends on the member's contract and state mandates; in general, medically necessary anesthesia services are available only in connection with covered underlying dental or medical services or when required by state mandate. Providers are advised to check the member's dental and medical benefits plan to determine covered services and whether prior authorization or utilization review is required.

Anesthesia services require appropriately trained, licensed providers and monitoring staff. Dentists administering anesthesia must be appropriately educated, trained and licensed; additional trained individuals (with Basic Life Support for Healthcare Providers certification and any state-required sedation licenses or equipment inspection certificates) must be present when advanced anesthetic techniques (e.g., IV or inhalation for profound levels of anesthesia) are used. The dentist or an appropriately trained individual must remain in the operatory to continuously monitor vital signs, and the dentist is responsible for drug management, facility/staff adequacy, and emergency equipment/drugs/protocols.

Evidence / Guideline references

Guideline sourcesAmerican Dental Association (ADA)

Pediatric guidanceAmerican Academy of Pediatrics (AAP) / American Academy of Pediatric Dentistry (AAPD)

Anesthesia societyAmerican Society of Anesthesiologists (ASA)

Oral & Maxillofacial SurgeryAmerican Association of Oral and Maxillofacial Surgeons (AAOMS)

Other specialty guidanceAdditional specialty guidance documents referenced in policy references list

Medically/Dentally Necessary: Services that are consistent with the member's diagnosis or condition; in response to a life-threatening condition or pain; to treat an injury, illness or infection related to the dentition; or to achieve a level of function to the dentition consistent with prevailing community standards.

Operational requirements

Medical conditions requiring general anesthesia must be supported by documentation from the oral surgeon/dentist and/or physician administering the anesthesia
Providers must submit supporting medical documentation
Time of general anesthesia begins when the dentist starts administering the sedative agent and non-invasive monitoring protocol
Dentist administering the anesthesia must remain in constant attendance with the patient until completion of the anesthesia procedure
Services are complete when the patient may be safely left under observation of trained personnel and the dentist may leave the operatory
Office anesthesia in excess of 60 minutes for dental or surgical procedure requires written rationale/documentation explaining the necessity> 60 minutes
Provide written justification for durations exceeding 60 minutes

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
D9219	evaluation for deep sedation or general anesthesia
D9222	deep sedation/general anesthesia first 15 minutes
D9223	deep sedation/general anesthesia each 15 minute increment
D9230	inhalation of nitrous oxide/analgesia, anxiolysis
D9239	intravenous moderate (conscious) sedation/analgesia first 15 minutes
D9243	intravenous moderate (conscious) sedation/analgesia each 15 minute increment

OpenPayer

Inhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Impact

Background & Evidence

Revision History