CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

Defines Anthem's medical necessity, clinical indications, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal blocks, conscious sedation (IV and non-IV), deep sedation/general anesthesia, and nitrous oxide when provided in conjunction with covered dental services; explains coverage is contingent on underlying covered dental/medical benefits and state/contract mandates.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeAnnual review (no material clinical changes)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit medical documentation from the oral surgeon, dentist and/or physician supporting the medical condition necessitating anesthesia when requesting general anesthesia or conscious sedation.

SourceLink

POLICY UPDATE CHANGES

Policy revised with last review date 11/11/2022 and published effective 01/01/2023.

11Referenced CDT codes

5Anesthesia modalities discussed

Coverage Summary

Scope: Defines Anthem's medical necessity, clinical indications, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal blocks, conscious sedation (IV and non-IV), deep sedation/general anesthesia, and nitrous oxide when provided in conjunction with covered dental services; coverage is contingent on the underlying covered dental/medical benefits and applicable state/contract mandates.

Medical Necessity and Clinical Indications

General medical necessity

Anesthesia services are covered only when medically/dentally necessary and in conjunction with covered dental services or state mandate:

ALL of the following

Service is consistent with the member's diagnosis or condition (response to life‑threatening condition or pain; to achieve function; to treat injury, illness or infection related to dentition).
Service is in accordance with generally accepted standards of dental practice (specialty society recommendations, peer‑reviewed evidence, recognized practicing dentists' views).
Service is provided in connection with an underlying dental or medical benefit that is covered under the member's contract or qualifies by state mandate.

When general anesthesia or conscious sedation may be considered

Member must satisfy ONE of the following criteria and have supporting documentation:

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, combinations of procedures).
Age for children is determined by contract/state mandate; Anthem follows contractual/state definitions for IV and inhalation anesthesia for children.
Member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia cannot be expected to provide a successful result (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity).
Must be verified by appropriate medical documentation from physician/oral surgeon/dentist administering anesthesia.
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed and for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral morbidity.
Documentation of behavioral/uncooperative status required.
Local anesthesia is ineffective for the member (e.g., due to acute infection, anatomic variations, or allergy); failed attempts must be documented and submitted for review.

Nitrous oxide (inhalation) indications and contraindications

Nitrous oxide may be considered when used with covered dental services if the following apply:

ALL of the following

Indications: ineffective local anesthesia administration; treatment of dental anxiety; special needs patients; individuals who are uncooperative or behaviorally challenged.
Contraindications (examples): severe respiratory compromise; first trimester pregnancy (potential teratogenic effects); history of stroke; hypotension and known cardiac conditions.

Local and regional anesthesia coverage notes

ANY of the following

Local anesthesia (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 may not be a covered service.

Operational/documentation requirements and limits

ALL of the following

Staffing/credentials: Dentists administering anesthesia must be appropriately educated, trained and licensed; additional individuals trained in Basic Life Support for Healthcare Providers must be present for advanced anesthetics (IV or inhalation).
If required by State, current equipment inspection certificate, sedation license and CPR certification are mandatory.
Monitoring must include continuous vital signs observation during active dental treatment until criteria for discharge to recovery area are met; oxygenation observation and oximetry are necessary; chest movement/respirations and circulation (blood pressure and heart rate) must be evaluated pre-, intra-, and post-operatively and documented.
Documentation: A complete anesthesia record must be maintained including names of all drugs administered, time and dosages, and all physiological parameters monitored and documented.

Coding (CDT codes referenced)

CDT codes referenced (informational only)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 12

1/2

Coding is provided for informational purposes only; inclusion of CDT codes does not guarantee coverage or reimbursement. Coverage of anesthesia codes depends on whether the underlying dental service is a covered benefit under the member's contract or a state mandate, and some codes (for example, regional and trigeminal division block anesthesia) may not be covered per policy notes.

Provider Actions and Documentation Requirements

Documentation Required

Medical documentation for anesthesia necessity

For general anesthesia or conscious sedation, submit medical documentation from the oral surgeon, dentist and/or physician supporting the medical condition necessitating anesthesia (examples: physical, intellectual, medically compromising conditions).

Documentation Required

Failed local anesthesia attempts

Document and submit failed attempts of local anesthesia administration (e.g., due to infection, anatomic variation, allergy) for review when claiming an anesthesia benefit.

Documentation Required

Anesthesia record and monitoring documentation

Maintain a complete anesthesia record that includes the names of all drugs administered, times of administration and dosages, and documentation of all physiological parameters monitored. Monitoring must include continuous observation of oxygenation (including oximetry), ventilation (chest movement/respirations) and circulation (blood pressure and heart rate) pre‑, intra‑, and post‑operatively.

Prior Authorization

Preauthorization/review may be required

Anesthesia services are subject to review per contractual requirements. Verify the member's dental/medical benefits and applicable state mandates to determine if preauthorization or review is required before providing anesthesia services.

Billing Rule

Office anesthesia >60 minutes requires rationale

When office anesthesia exceeds 60 minutes for any dental or surgical procedure, submit a written rationale and full supporting documentation, including all associated X‑ray images, progress notes, operative report and a complete anesthesia record showing start and stop times of incremental drug administration.

Denial Risk

Coverage contingent on underlying benefit

Coverage of anesthesia is contingent on the underlying dental service being a covered benefit under the member's contract or by state mandate; claims may be denied if the underlying procedure is not covered.

Background and Guideline References

Background: Anthem references professional guidelines and specialty society recommendations — including the American Dental Association (ADA), American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Society of Anesthesiologists (ASA), and other specialty guidelines — to inform safe practice, monitoring, and documentation for dental anesthesia and sedation.

Anthem's policy emphasizes that dentists must be appropriately trained and licensed, monitoring must include continuous observation of oxygenation, ventilation and circulation with complete anesthesia records maintained, and that coverage still depends on the member's underlying covered services and applicable state or contract mandates.

Definitions

TermMedically/Dentally Necessary

DefinitionServices consistent with the member's diagnosis or condition to address life-threatening condition or pain, achieve functional dentition, or treat injury/illness/infection related to dentition; aligned with generally accepted standards of dental practice.

Standards referencedSpecialty society recommendations, peer-reviewed evidence, and views of recognized practicing dentists are considered part of generally accepted standards of dental practice.

OpenPayer

Inhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

Coverage Summary

Medical Necessity and Clinical Indications

Coding (CDT codes referenced)

Provider Actions and Documentation Requirements

Background and Guideline References

Revision History