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 Anesthesia Coverage & Documentation Update …
    Ask Trek AI about this page
    CurrentAnthemPolicy 09-201

    Inhalation and Local Anesthesia (2022 Policy)

    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, 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
    Last ReviewOct 20, 2021
    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).

    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.

    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.

    Key thresholds and quick facts
    Office anesthesia duration requiring extra documentation> 60 minutes
    Effective Date2022-01-01
    Last Review2021-10-20
    Policy Number09-201
    Child-age noteAAP/AAPD define child as 0 to 21 but Anthem follows contract and state-mandated ages for benefit purposes

    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

    Coding

    CDT codes mentioned (informational list)CPT/CDT
    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

    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

    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.

    Revision History

    10/20/2021annual_reviewLatest

    Policy revised with annual review on 10/20/2021 (Nature of Change = Annual Review); no material clinical policy change.

    Policy Summary
    PayerAnthem
    PolicyInhalation and Local Anesthesia (2022 Policy)
    Policy CodePolicy 09-201
    Change TypeAnnual Review
    Effective DateJan 1, 2022
    Last ReviewOct 20, 2021
    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
    On This Page
    Coverage SummaryMedical Necessity CriteriaCodingProvider ActionsBackground and GuidanceRevision History

    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 is ineffective for the member (reasons such as acute infection, anatomic variations, or allergy). Failed attempts of local anesthesia must be documented and submitted for review

      documentation required

    • Member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised

    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
  1. Start and stop times of drug administration
  2. Associated operative notes and progress notes
  3. X-ray images when office anesthesia exceeds 60 minutes
    4. 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