CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2022 Policy)

Defines medical necessity, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal blocks, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and nitrous oxide when provided with covered dental services; includes provider requirements and coding references. Applies to Anthem commercial/dental plans subject to contract and state mandates.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeAnnual Review

Effective DateJan 1, 2022

Next Review Date

Key ActionWhen general anesthesia or conscious sedation is used for medical reasons, submit supporting documentation from the oral surgeon, dentist and/or physician explaining the medical condition that necessitates anesthesia; failed local anesthesia attempts must be documented when claimed.

SourceLink

POLICY UPDATE CHANGES

Policy revised with annual review on 10/20/2021 (Nature of Change = Annual Review).

11CDT codes listed

5Coverage criteria items

4Nitrous oxide contraindications

Coverage Summary

Scope: This policy (Anesthesia, Guideline #09-201) applies to Anthem commercial/dental plans and defines medical necessity, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal division block anesthesia, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and nitrous oxide. Policy number: 09-201. Effective date/publish date: 01/01/2022 with last review 10/20/2021. Coverage stance: mixed — anesthesia services may be covered when medically/dentally necessary and performed in conjunction with covered dental services or when required by state mandate, subject to contract and plan-specific provisions.

Key condition: coverage is contingent on the underlying dental service being covered under the member's dental or medical benefits plan or being required by state law, and on meeting generally accepted standards of dental practice. The policy addresses monitoring, documentation, staffing, and duration rules and notes that some modalities (for example, regional/trigeminal block anesthesia) may not be covered depending on the plan.

Medical Necessity Criteria

General medical necessity

Anesthesia services are covered when medically/dentally necessary and performed in conjunction with covered dental services or when required by state mandate. Covered when ALL of the following are met:

ALL of the following

Service is consistent with the member's diagnosis or condition
Service is rendered in response to a life-threatening condition or pain; or to treat an injury, illness or infection related to the dentition; or to achieve a level of function consistent with community standards
Service is in accordance with generally accepted standards of dental practice and not primarily for convenience or cosmetic
Anesthesia provided in conjunction with an underlying dental service that is covered under the member's dental or medical benefits plan, or coverage is mandated by state law

Deep sedation/general anesthesia and conscious sedation (IV and non-IV)

To qualify for benefit, the member must satisfy ONE of the following criteria. Documentation from dentist/oral surgeon/physician is required to support medical conditions.

ANY of the following

Member is a child, up to the age defined by contract, with a dental condition requiring repairs of significant complexity (examples: multiple restorations, pulpal therapy, extractions, or combinations of procedures)
examples preserved from source
Member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia cannot be expected to provide a successful result (examples include intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity)
examples preserved from source
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs where lack of treatment would likely result in oral pain, infection, tooth loss, or other increased oral morbidity

Local anesthesia

Local anesthetic administration policy statement

Administration of local anesthetic (traditional, electronic, buffered, etc.) is considered inclusive of all dental procedures and is not eligible for a separate benefit unless a specific plan allows coverage

Regional and trigeminal division block anesthesia

Regional and trigeminal division block anesthesia policy statement

Regional and trigeminal block anesthesia may not be a covered service

Coding

CDT codes mentioned (informational list)CPT/CDT

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

1–10 of 12

1/2

Provider Actions

Documentation Required

Support medical necessity with documentation

When general anesthesia or conscious sedation is used for medical reasons, submit supporting documentation from the oral surgeon, dentist and/or physician explaining the medical condition that necessitates anesthesia; failed local anesthesia attempts must be documented when claimed.

Documentation Required

Maintain complete anesthesia record

Maintain anesthesia record including drug names, dosages, administration times, physiologic monitoring data, start/stop times and associated operative notes and x-rays when duration >60 minutes.

Names of all drugs administered
Times of administration
Dosages (including local anesthetics and other anesthetic drugs)
All physiological monitoring parameters (e.g., pulse oximetry, ventilation, circulation)
Pre-, intra-, and post-operative blood pressure and heart rate documentation
Start and stop times of drug administration
Associated operative notes and progress notes
X-ray images when office anesthesia exceeds 60 minutes

Prior Authorization

Check plan contract and state mandates

Confirm that the underlying dental service and anesthesia are covered under the member's dental or medical benefits plan and any state mandates; utilization review may be performed per plan.

Documentation Required

Monitoring and staffing requirements

When more advanced anesthetics (such as IV or inhalation) are used to induce more profound levels of anesthesia, additional individuals trained in Basic Life Support for Healthcare Providers must be present. If required by the state, a current equipment inspection certificate, sedation license and CPR certification are mandatory.

Denial Risk

Local anesthesia billed separately

Claims for local anesthesia separate from a specific plan allowance may be denied because local anesthesia is considered inclusive of all dental procedures unless the specific plan allows separate coverage.

D9210
D9215

Background and Guidance

Background: This policy outlines the evaluation of anesthesia benefits for dental services, emphasizing that coverage is contingent on the underlying dental service being covered under the dental or medical benefits plan or when required by state mandate, and that benefits must meet generally accepted dental standards and contractual requirements.

The policy references professional guidance for monitoring and pediatric care, including American Dental Association (ADA) recommendations and the American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) guidelines for monitoring and management of pediatric patients during and after sedation, as well as AAOMS and other specialty guidance for practice and monitoring.

Note on child definition: academies (AAP/AAPD) define a child as ages 0 to 21, but for benefit purposes Anthem follows the ages defined by the member's contract and any state-mandated ages for IV and inhalation anesthesia.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeAnnual Review

Effective DateJan 1, 2022

Next Review Date

SourceLink

On This Page

OpenPayer

Inhalation and Local Anesthesia (2022 Policy)

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions

Background and Guidance

Revision History