CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

Defines medical necessity, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal block, conscious sedation (intravenous and non-intravenous), deep sedation/general anesthesia, and nitrous oxide inhalation in dental settings. Applies when anesthesia services are provided in conjunction with covered dental or applicable medical services and per contract/state mandates.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit medical documentation demonstrating the medical condition(s) necessitating general anesthesia or conscious sedation and maintain a complete anesthesia record including drug names, dosages, administration times, and continuous physiologic monitoring.

SourceLink

POLICY UPDATE CHANGES

Policy status indicated as Revised with last review date 11/01/2023 and publish date 01/01/2024.

MultipleCovered Indications (conditional)

D9210-D9613CDT codes listed (informational)

>60minExtended anesthesia requires documentation

Coverage Summary

Scope: Defines medical/dental necessity, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal block, conscious sedation (intravenous and non-intravenous), deep sedation/general anesthesia, and nitrous oxide inhalation for dental settings when provided in conjunction with covered dental or applicable medical services and as allowed by contract or state mandate.

Coverage stance: Mixed — anesthesia modalities may be conditionally covered when medically/dentally necessary and when plan/contract or state mandate allows; the policy includes an informational CDT code list (e.g., D9210–D9613).

Policy dates: Effective date 2024-01-01; Last review date 2023-11-01.

Key thresholds and quick facts

Office anesthesia time limit> 60 minutes requires written rationale and documentation (including X-rays, progress notes, operative report and complete anesthesia record showing drug start/stop times)

CDT codes (informational)D9210-D9613 (examples: D9210, D9211, D9212, D9215, D9219, D9222, D9223, D9230, D9239, D9243, D9248, D9613)

Covered Indications (conditional)Multiple anesthesia modalities may be covered when medically/dentally necessary and performed with covered dental services or per state mandate (e.g., pediatric complex repairs, physical/medical impairments, extreme uncooperativeness, failed local anesthesia, extensive trauma)

Documentation requiredComplete anesthesia record with drug names, doses, administration times and physiologic monitoring (oxygenation, ventilation, circulation) documented pre/intra/post-op

Monitoring/staffingDentist must remain in constant attendance; additional BLS-trained personnel required when IV/inhalation induce profound anesthesia

Medical-Necessity Criteria

Medically/Dentally Necessary

Rendered: Medically/Dentally Necessary means Medical/Dental Services that meet ALL of the following:

ALL of the following

Consistent with the Member's diagnosis or condition
In response to a life-threatening condition or pain; or to achieve a level of function to the dentition consistent with prevailing community standards for the diagnosis or condition
To treat an injury, illness or infection related to the dentition

Coverage of General Anesthesia / Conscious Sedation

These services may be benefitted when performed in conjunction with covered dental services and when documentation supports medical necessity; member must satisfy ONE of the following:

ONE of

Member is a child, up to the age defined by contract, with a dental condition requiring complex repairs (e.g., multiple restorations, pulpal therapy, extractions, or combinations) that justify general anesthesia
Member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia cannot be expected to provide a successful result and which under anesthesia can be expected to produce a superior result (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity); must be verified by appropriate medical documentation
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
Local anesthesia is ineffective for the member (e.g., acute infection, anatomic variations, allergy); failed attempts of local anesthesia must be documented and submitted for review

Nitrous Oxide / Inhalation Analgesia Indications and Contraindications

Nitrous oxide may be indicated when ALL of the following apply or is contraindicated in listed conditions:

May be indicated for ONE of

Ineffective local anesthesia administration
Treatment of dental anxiety
Special needs patients
Individuals who are uncooperative or behaviorally challenged

Contraindicated for ONE of

Patients with severe respiratory compromise

Coding (informational)

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 12

1/2

Billing Rule

Local anesthesia billing note

Local anesthesia is generally considered inclusive of dental procedures and is not eligible for a separate benefit unless a specific plan allows coverage. Providers should verify member benefits and the contract to confirm whether local anesthesia is covered separately for the member.

Local anesthesia typically bundled
Verify member benefits/contract

Provider Actions & Documentation

Documentation Required

Medical documentation to support general anesthesia/conscious sedation

Submit medical documentation from the oral surgeon, dentist and/or physician demonstrating the medical condition(s) necessitating general anesthesia or conscious sedation. Examples of documentation to include: failed local anesthesia attempts, and medical diagnoses or conditions such as intellectual disability, cerebral palsy, epilepsy, severe cardiac problems, or other medically compromising conditions that justify use of anesthesia.

Document failed local anesthesia attempts
Provide medical diagnoses/conditions (e.g., intellectual disability, cerebral palsy, epilepsy, severe cardiac problems)

Documentation Required

Anesthesia record and vital sign monitoring

Maintain a complete anesthesia record including drug names, dosages, administration times, and continuous physiologic monitoring documented pre-, intra-, and post-operatively. Required monitoring elements include oxygenation (pulse oximetry and clinical observation), ventilation (continuous observation of chest movement and respirations), and circulation (blood pressure and heart rate documented pre-, intra-, and post-operatively). Records must be maintained as part of the anesthesia documentation.

Oxygenation (pulse oximetry, mucosal color observation)
Ventilation (continuous chest movement observation, respirations documented)
Circulation (blood pressure and heart rate pre-, intra-, post-operatively)

Documentation Required

Extended anesthesia justification

For office anesthesia exceeding 60 minutes, provide a written rationale explaining the necessity and submit supporting materials: all associated X-ray images, progress notes, the operative report, and a complete anesthesia record indicating start and stop times of incremental drug administration.

Written rationale for >60 minutes
Associated X-rays
Progress notes and operative report
Complete anesthesia record with start/stop times of incremental drug administration

Prior Authorization

Check plan/contract for coverage

Confirm with the member's plan whether anesthesia services are covered under the dental benefits, medical benefits, or are required by state mandate before providing services. Benefits and coverage may vary by contract and state requirements; verify contract-specific coverage to determine applicability.

Confirm dental vs. medical benefit coverage
Check for state mandates affecting coverage

Documentation Required

Provider qualifications and certifications

Ensure the dentist and any additional staff involved hold required training and licenses and maintain current Basic Life Support (BLS) for Healthcare Providers certification. If required by state regulation, maintain current equipment inspection certificates, sedation licenses, and CPR certification. The dentist administering anesthesia must remain in constant attendance until completion of the anesthesia procedure.

Required training and licensure for dentist and staff
Basic Life Support (BLS) for Healthcare Providers certification
Equipment inspection certificate and sedation licenses if state-required
Dentist must remain in constant attendance during anesthesia

Background and Guidance References

Background: Anthem ties coverage of dental anesthesia to medical/dental necessity and plan/contract or state mandates and references professional guidance from the ADA, AAP/AAPD, ASA and other specialty sources.

Monitoring and staffing: The policy requires continuous monitoring of oxygenation (including pulse oximetry), ventilation (chest movement), respirations, circulation (blood pressure and heart rate) pre-, intra- and post-operatively, and that the dentist (or an appropriately trained individual at the dentist's direction) remain in the operatory during active treatment. When IV or inhalation are used to induce profound anesthesia, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist/oral surgeon.

Documentation: An appropriate, complete anesthesia record must be maintained including drug names, times, dosages, and physiologic parameters. For office anesthesia exceeding 60 minutes, written rationale and supporting documentation (X-rays, progress notes, operative report and a complete anesthesia record with start/stop times of incremental drug administration) are required.

Contraindications and nitrous oxide: Nitrous oxide may be indicated for ineffective local anesthesia, dental anxiety, special needs patients, or uncooperative individuals, and is contraindicated in listed conditions such as severe respiratory compromise, first trimester pregnancy, history of stroke, and hypotension/known cardiac conditions.

Bundling position: Local anesthesia (traditional, electronic, buffered, etc.) is considered inclusive of dental procedures and is not eligible for separate benefit unless a specific plan allows coverage; regional and trigeminal division block anesthesia may not be a covered service.

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

OpenPayer

Inhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

Coverage Summary

Medical-Necessity Criteria

Coding (informational)

Provider Actions & Documentation

Background and Guidance References

Revision History