CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Defines Anthem's medical necessity, coverage position, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal block, inhalation nitrous oxide, intravenous and non-intravenous conscious sedation, deep sedation/general anesthesia in dental settings. Applies where anesthesia is provided in conjunction with dental services and subject to member contract and state mandates.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionProvide medical documentation to support need for general anesthesia or conscious sedation and maintain a complete anesthesia record including drug names/doses/times and physiologic monitoring.

SourceLink

POLICY UPDATE CHANGES

Annual review completed on 10/20/2021 with committee; no specific clinical policy statement changes indicated in document.

11CDT codes listed

ConditionalGen. anesthesia/Conscious sedation

Not coveredLocal anesthesia separate benefit

Coverage Summary

Policy 09-201 (Subject: Inhalation and Local Anesthesia for Dental Services) is effective 2022-01-01 with last review on 2021-10-20. Coverage stance: mixed. Scope: defines Anthem's medical necessity and coverage positions, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal block, inhalation nitrous oxide, intravenous and non-intravenous conscious sedation, and deep/general anesthesia in dental settings, and notes that benefit application is subject to the member's contract and state mandates.

Anthem considers anesthesia benefits available only when medically/dentally necessary and in conjunction with covered underlying dental or medical services or when required by state mandate; check the member's dental and medical benefits plan to determine covered services. Anesthesia coverage decisions follow the guideline and the member's contract and state mandates.

Key facts

Policy number09-201

Effective date2022-01-01

Last review2021-10-20

Coverage stanceMixed / Conditional — anesthesia covered only when medically/dentally necessary and in conjunction with covered dental/medical services or state mandate

CDT codes listed (count)11

General anesthesia / Conscious sedationConditional — may be considered when criteria and documentation are met

Local anesthesia separate benefitNot separately covered (considered inclusive of dental procedures unless plan allows separate coverage)

Coding

CDT codes (informational list)mixed

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 11

1/2

Provider Actions & Billing Impact

Prior Authorization

Review/authorization may be required per contract

Coverage and any required review/authorization depend on the member's specific dental and medical benefits contract and applicable state mandates. Confirm coverage by checking the member's plan and contact customer service if review or prior authorization is required.

Documentation Required

Medical documentation to support advanced anesthesia

Medical documentation from the treating physician, oral surgeon, or dentist is required to support the need for general anesthesia or conscious sedation. Documentation should justify conditions such as medically compromising diagnoses, failed local anesthesia attempts, or complex pediatric cases that make local anesthesia unlikely to be successful.

Documentation Required

Anesthesia record requirements

Maintain a complete anesthesia record that documents the names of all drugs administered, dosages, and times of administration, and includes physiologic monitoring parameters with start and stop times.

Documentation Required

Monitoring and staffing requirements

When IV or inhalation agents are used, additional personnel trained in Basic Life Support for Healthcare Providers must be present. An appropriately trained individual must remain in the operatory to continuously monitor oxygenation, ventilation and circulation, and monitoring must be documented.

Documentation Required

Extended anesthesia time justification

Office anesthesia that exceeds 60 minutes requires a written rationale and documentation explaining the medical necessity for the extended anesthesia time.

Denial Risk

Local anesthesia reporting

Local anesthesia (including traditional, electronic, buffered techniques) is considered inclusive of dental procedures and is generally not eligible for a separate benefit; separate claims for local anesthesia (e.g., D9210, D9215) may be denied unless the specific plan allows separate coverage.

Affected CDT codes: D9210, D9215

Background & Definitions

Anthem's guideline states that anesthesia benefits are available only in connection with underlying services that are covered under the dental or medical benefits plan or when the services qualify based on state mandate, and advises verification of the member's plan for covered services. The guideline aligns with ADA and AAP/AAPD recommendations regarding pediatric sedation monitoring and references those organizations for safe practice.

The policy requires that dentists administering anesthesia be appropriately educated, trained and licensed, that additional BLS-trained personnel be present when IV or inhalation agents are used to induce more profound anesthesia, and that emergency management responsibilities (including drugs, equipment, facility/staff adequacy and office protocols) be met. Monitoring and documentation requirements include continuous vital sign monitoring (oxygenation, pulse oximetry), observation of ventilation and circulation (blood pressure and heart rate pre/intra/post-op), and maintenance of a complete anesthesia record with drug names/doses/times and physiologic parameters. Office anesthesia exceeding 60 minutes requires written rationale/documentation.

Definitions

Medically/Dentally NecessaryServices consistent with the member's diagnosis or condition; in response to a life‑threatening condition or pain; to treat injury/illness/infection related to the dentition; or to achieve dentition function consistent with community standards.

ChildAlthough AAP/AAPD define child as ages 0 to 21, for benefit purposes Anthem follows the contract and state‑mandated ages for anesthesia.

Revision History

2021-10-20annual_reviewLatest

Annual review completed on 10/20/2021 with committee; no specific clinical policy statement changes indicated in document.

2020-12-06annual_review

Annual review completed on 12/06/2020 with committee.

2020-11-12annual_review

Annual review completed on 11/12/2020 with committee.

2018-02-06revision

Revision on 02/06/2018 addressing appropriateness and medical necessity.

2014-01-01initial_publish

Initial version published on 01/01/2014.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Inhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Impact

Background & Definitions

Revision History