CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2023 Policy)

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Defines medical necessity, monitoring, documentation, and coverage guidance for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide when provided with covered dental services; includes CDT code examples and clinical/operational requirements.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2023 Policy)

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2023

Last ReviewNov 11, 2022

Next Review Date

Key ActionSubmit documentation from oral surgeon, dentist and/or physician supporting medical conditions that necessitate general anesthesia or conscious sedation, including failed local anesthesia attempts where applicable.

SourceLink

POLICY UPDATE CHANGES

Policy revised (status shows 'Revised'), latest review date 11/11/2022; published date 01/01/2023.

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CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2023 Policy)

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Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2023 Policy)

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2023

Last ReviewNov 11, 2022

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Policy revised (status shows 'Revised'), latest review date 11/11/2022; published date 01/01/2023.

Coverage Summary

Policy 09-201 addresses coverage and medical necessity for dental anesthesia modalities including local, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide. Status is Revised/CURRENT; published date 01/01/2023 with last review on 11/11/2022. Coverage stance is mixed/conditional: anesthesia services may be covered when medically/dentally necessary and when provided in conjunction with covered dental or medical services or as required by state mandate. Applicability and payment depend on the member's contract, state requirements, and applicable CDT coding (informational examples included).

Key thresholds and policy metadata

Office anesthesia time threshold> 60 minutes requires written rationale and documentation (including x-rays, progress notes, operative report and complete anesthesia record with start/stop times)

Policy effective date2023-01-01

Last review date2022-11-11

Policy number09-201

SubjectDental anesthesia services (local, regional, sedation, general, nitrous oxide)

Medical Necessity Criteria

General Medical Necessity

Anesthesia services are covered only when medically/dentally necessary and in conjunction with covered dental services or state mandates. 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/infection related to the dentition, or to achieve dentition function consistent with prevailing community standards.
Service is provided in connection with underlying dental or medical services that are covered under the member's plan or when required by state mandate.
Anesthesia administration and monitoring meet required standards (trained/licensed provider, monitoring of oxygenation, ventilation, circulation, and complete anesthesia record).

Coding

CDT codes (informational list)CPT

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 & Operational Requirements

Documentation Required

Support medical necessity for general anesthesia/conscious sedation

Submit documentation from the oral surgeon, dentist and/or physician that supports the medical conditions necessitating general anesthesia or conscious sedation. Include documentation of failed local anesthesia attempts when applicable.

Documentation Required

Maintain anesthesia record and monitoring documentation

Maintain a complete anesthesia record that includes names of all drugs administered, dosages, and times of administration. Continuously monitor and document oxygenation (including pulse oximetry and observation of mucosal color), ventilation (chest movement and respirations), and circulation (blood pressure and heart rate) pre-, intra-, and post-operatively. An appropriately trained individual must remain in the operatory to monitor these parameters until discharge criteria are met.

Background & Definitions

This policy provides guidance on the medical necessity and appropriateness of local, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide for dental services, consistent with ADA, AAP, AAPD and ASA guidance and related specialty recommendations. It outlines clinical indications, monitoring, documentation, provider qualifications and safety requirements for anesthesia in dental practice.

Coverage of anesthesia services is available only when services meet medical/dental necessity and are in connection with underlying covered dental or medical services or when required by state mandate. The determination of medical/dental necessity follows generally accepted standards of dental practice and does not itself guarantee that a service is a covered benefit under a member's plan; members and providers should check the specific benefit contract and state mandates to determine coverage and any prior authorization or licensing requirements.

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

Revision History

2022-11-11reviewLatest

Policy revised, latest review date 11/11/2022; published date 01/01/2023 (not a material change)

2023-01-01published

Policy revised, latest review date 11/11/2022; published date 01/01/2023 (not a material change)

Deep Sedation/General Anesthesia and Conscious Sedation (IV and non-IV)

To qualify for benefit, member must satisfy ONE of the following criteria; documentation required from treating clinicians to support medical necessity.

ONE of

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).
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).
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed, and lack of treatment could result in oral pain, infection, loss of teeth, or other increased oral morbidity.
Local anesthesia is ineffective for the member (reasons such as acute infection, anatomic variations or allergy); failed attempts must be documented and submitted for review.
Member has sustained extensive oral‑facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.

Medical conditions requiring general anesthesia must be supported by documentation submitted by the oral surgeon, dentist and/or physician administering the anesthesia.

Time of general anesthesia begins when dentist starts administering the sedative agent and non-invasive monitoring protocol; dentist must remain in constant attendance until completion of anesthesia procedure.

Services considered complete when patient may be safely left under observation of trained personnel and dentist may leave the operatory.

Office anesthesia in excess of 60 minutes for any dental or surgical procedure requires written rationale/documentation including x-rays, progress notes, operative report and complete anesthesia record with start/stop times of incremental drug administration.