CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2025 Policy)

Defines Anthem's clinical policy for coverage and medical necessity of dental anesthesia services (local, regional, trigeminal blocks, inhalation nitrous oxide, IV and non‑IV conscious sedation, deep sedation and general anesthesia) when performed with covered dental procedures and includes monitoring, documentation and facility/staff requirements.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2025 Policy)

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2025

Next Review Date

Key ActionSupport medical necessity with documentation: include radiographs, progress notes, operative report and complete anesthesia record with start/stop times for office anesthesia >60 minutes.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised; last review 10/31/2024 and published date 01/01/2025.

12Listed CDT/related anesthesia codes

5Clinical indications for GA/conscious sedation

4Nitrous oxide contraindications

Coverage Summary

Defines Anthem's clinical policy for coverage and medical necessity of dental anesthesia services including local anesthesia, regional and trigeminal blocks, inhalation nitrous oxide, intravenous and non‑intravenous conscious sedation, and deep sedation/general anesthesia when performed in conjunction with covered dental procedures. CDT codes associated with these modalities include D9210, D9211, D9212, D9215, D9219, D9222, D9223, D9230, D9239, D9243, D9248, and D9613.

Medical Necessity and Coverage Criteria

Local Anesthesia

Covered status and separability

Administration of local anesthetic (traditional, electronic, buffered, etc.) is considered inclusive of (part of) all dental procedures unless a specific plan allows separate coverage.

Local anesthesia is not eligible for a separate benefit unless specified by member's plan.

Regional and Trigeminal Division Block Anesthesia

Regional and trigeminal block anesthesia may not be a covered service.

Deep Sedation/General Anesthesia and Intravenous/Non-Intravenous Conscious Sedation

These modalities may be covered when performed in conjunction with covered dental services and when medical/dental necessity criteria are met. To qualify the member must satisfy ONE of the following:

ONE of

The 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).
Anthem follows contract/state defined ages for IV and inhalation anesthesia for children; AAP/AAPD define child as 0-21 but benefit follows contract.
The member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia (with or without adjuncts) cannot be expected to provide a successful result, and for which treatment under anesthesia can be expected to produce a superior result.
Conditions include but are not limited to intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems and hyperactivity; must be supported by medical documentation.
The member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs which should not be postponed and where lack of treatment may result in oral pain, infection, loss of teeth, or increased oral morbidity.
Behavioral justification must be documented.
The member for whom local anesthesia is ineffective (acute infection, anatomic variations, allergy).
Failed attempts of local anesthesia administration must be documented and submitted for review.
The member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.

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

Operational requirements: The level of anesthesia is determined by documentation of the anesthetic agent's effect on the central nervous system, not route of administration.

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

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

Operational requirements: Office anesthesia in excess of 60 minutes for any dental or surgical procedure requires written rationale/documentation explaining the necessity including radiographic images, progress notes, operative report and complete anesthesia record indicating start and stop times of incremental drug administration.

Inhalation of Nitrous Oxide / Analgesia (D9230)

May be benefited when appropriate in conjunction with covered dental services.

Indications include ineffective local anesthesia administration; treatment of dental anxiety; special needs patients; individuals who are uncooperative or behaviorally challenged.

Contraindications include (but not limited to) severe respiratory compromise; first trimester pregnancy; history of stroke; hypotension and known cardiac conditions.

Monitoring and Documentation Requirements

Monitoring and documentation must be maintained for anesthesia services.

Vital signs monitoring: A dentist or appropriately trained individual must remain in the operatory during active dental treatment to monitor patient's vital signs continuously until discharge criteria to recovery area are met.

Oxygenation and pulse oximetry: Monitoring must include observation of proper oxygenation (including mucosa color), continual evaluation of skin or blood, and oxygen saturation by pulse oximetry.

Ventilation: chest movement must be continually observed; respirations must be verified and documented by trained personnel.

Circulation: blood pressure and heart rate must be evaluated pre-operatively, intra-operatively and postoperatively and documented.

Anesthesia documentation:

Staffing, Facility and Emergency Management

Requirements when advanced anesthetics are used

Trained personnel: When IV or inhalation anesthetics are used to induce more profound levels of anesthesia, additional individuals trained in either Advanced or Basic Life Support (state specific) for Healthcare Providers must be present in addition to the dentist/oral surgeon.

State-required certifications and equipment: If required by the State, a current equipment inspection certificate, sedation license and CPR certification are mandatory.

Dentist responsibilities: The dentist is responsible for drug management, adequacy of facility and staff, diagnosis and treatment of emergencies related to administration of IV or inhalation drugs and must provide appropriate equipment, drugs and office protocol for emergency management.

Provider Action Items

Prior Authorization

Prior review for general anesthesia/conscious sedation may be required

Coverage of deep sedation, general anesthesia and conscious sedation is conditional on meeting clinical criteria and submission of supporting medical documentation. Providers should verify the member's contract and obtain any required preauthorization per member benefits.

Documentation Required

Support medical necessity with documentation

Medical conditions requiring general anesthesia must be supported by documentation from the oral surgeon, dentist and/or physician. Necessary documentation for office anesthesia in excess of 60 minutes includes radiographic images, progress notes, operative report and a complete anesthesia record indicating start and stop times of incremental drug administration.

Radiographs
Progress notes
Operative report
Complete anesthesia record with start/stop times for office anesthesia >60 minutes

Documentation Required

Monitor and record physiologic parameters

Monitoring must be continuous and documented. A dentist or appropriately trained individual must remain in the operatory during active treatment to monitor vital signs. Documentation must include oxygenation (including mucosa color), pulse oximetry, ventilation (chest movement and respirations), blood pressure and heart rate pre-, intra- and post-operatively, and a complete anesthesia drug administration record with names, times and dosages of drugs administered.

Continuous oxygenation monitoring (including mucosa color)
Pulse oximetry
Ventilation monitoring (chest movement, respirations)
Blood pressure and heart rate pre-, intra- and post-operatively
Anesthesia drug administration record (names, times, dosages)

Documentation Required

Document failed local anesthesia attempts

If local anesthesia is ineffective, failed attempts of local anesthesia administration must be documented and submitted for review to justify use of general anesthesia.

Billing Rule

Local anesthesia bundled

The administration of local anesthetic (traditional, electronic, buffered, etc.) is considered inclusive of (part of) all dental procedures and is not eligible for a separate benefit unless a specific plan allows separate coverage.

D9210
D9215
Local anesthesia is considered part of dental procedures and not eligible for separate billing unless the plan allows separate coverage

Background and Definitions

Anthem defines the continuum of depth of sedation by the effect of the anesthetic agent on the central nervous system: General Anesthesia is a drug-induced loss of consciousness where patients are unarousable and often require airway assistance and possible positive pressure ventilation; Deep Sedation/Analgesia is a depressed consciousness where patients are not easily aroused but respond purposefully after repeated or painful stimulation and may require airway support; Intravenous Moderate (Conscious) Sedation/Analgesia produces a depressed consciousness with adequate spontaneous breathing, preserved cardiovascular function and the patient able to follow commands; and Minimal Sedation (Anxiolysis) allows normal response to verbal commands with preserved airway and cardiovascular function.

When IV or inhalation anesthetics are used to induce more profound levels of anesthesia, Anthem requires additional individuals trained in Advanced or Basic Life Support (state specific) to be present in addition to the dentist/oral surgeon. If required by the State, a current equipment inspection certificate, sedation license and CPR certification are mandatory. The dentist remains responsible for drug management, facility and staff adequacy, emergency diagnosis and treatment, and must provide appropriate equipment, drugs and office protocol for emergency management.

Monitoring and documentation requirements include continuous in‑operatory monitoring of vital signs by the dentist or an appropriately trained individual until discharge criteria are met, observation of proper oxygenation (including mucosa color), pulse oximetry, continuous ventilation assessment (chest movement and documented respirations), evaluation and documentation of blood pressure and heart rate pre-, intra- and post-operatively, and maintenance of a complete anesthesia record listing all drugs, times and dosages and physiologic parameters.

For benefit determinations involving children, Anthem follows contract and state-defined ages for IV and inhalation anesthesia (not solely the AAP/AAPD 0–21 year definition) when applying coverage criteria.

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

OpenPayer

Inhalation and Local Anesthesia (2025 Policy)

Coverage Summary

Medical Necessity and Coverage Criteria

Provider Action Items

Coding (CDT / ICD-10)

Background and Definitions

Revision History

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