CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

Defines Anthem's policy for coverage and medical necessity of local, regional, inhalation (nitrous oxide), moderate/ conscious sedation, deep sedation and general anesthesia in dental settings, including monitoring, documentation, and provider requirements; includes CDT code list for informational purposes. Applies to dental procedures and specifies pediatric considerations and contraindications.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit medical documentation (radiographs, progress notes, operative report and a complete anesthesia record with start/stop times and incremental drug administration) to support medical necessity for general anesthesia.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised with last review date 10/31/2024 and publish date 01/01/2025.

1Documented Pediatric Age Threshold Reference

12Pediatric age (ADA guidance avoid pre-op oral sedatives)

60Office anesthesia minute threshold mentioned

Coverage Summary

Medical-Necessity Criteria

General Medical Necessity Requirements

Covered when ALL of the following are met:

ALL of the following

Services must be consistent with the Member's diagnosis or condition (medically/dentally necessary).
Services rendered in response to a life-threatening condition or pain; to treat injury, illness or infection related to the dentition; or to achieve function consistent with prevailing community standards.
Dentist administering anesthesia must be appropriately educated, trained and licensed; additional individuals trained in Advanced or Basic Life Support (state specific) must be present when advanced anesthetics (IV or inhalation) are used, and state-required equipment inspection certificate, sedation license and CPR certification must be maintained.
Monitoring and documentation requirements met: continuous vital sign monitoring in operatory until criteria for discharge to recovery met; oxygenation observation (including pulse oximetry), ventilation/chest movement observation and documentation of respirations, circulation monitoring (blood pressure and heart rate pre/intra/post-operative) and a complete anesthesia record (names, drug names, times, dosages, physiologic parameters).
Emergency management capabilities present: appropriate equipment, drugs, office protocol, and staff responsibilities for emergencies related to anesthesia.

Local Anesthesia

Coverage position:

Administration of local anesthetic (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

Coverage position:

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

Deep Sedation / General Anesthesia / IV Moderate (Conscious) Sedation / Non-IV Conscious Sedation

These procedures may be benefitted when performed in conjunction with covered dental services and when medical necessity criteria are met:

Member qualifies if ONE of the following is met

Member is a child (age up to contract-defined age) with a dental condition requiring repairs of significant complexity (e.g., 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; conditions include but are not limited to intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity (verification via appropriate medical documentation required).
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed and for whom lack of treatment would result in oral pain, infection, tooth loss, or other increased oral morbidity.

Inhalation of Nitrous Oxide / Analgesia (D9230)

Nitrous oxide may be benefitted when appropriate in conjunction with covered dental services and when indicated:

Indications (ONE or more):

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

Contraindications (ONE or more):

Patients with severe respiratory compromise.

Provider Actions

Prior Authorization

Pre-approval / review for anesthesia services

To determine whether pre-approval or a formal review is required for anesthesia services for a specific member, contact the customer service number on the member's ID card or review the member's benefit contract. Medical conditions that necessitate general anesthesia or conscious sedation must be supported by documentation from the oral surgeon, dentist and/or physician administering the anesthesia and may be subject to review per the member's contract.

Documentation Required

Medical documentation for anesthesia necessity

When medical necessity for general anesthesia or conscious sedation is claimed, submit supporting documentation from the provider administering the anesthesia. Required documentation includes radiographic images, relevant progress notes, the operative report, and a complete anesthesia record that specifies start and stop times, incremental drug administration, drug names and dosages.

Radiographic images
Progress notes
Operative report
Complete anesthesia record with start/stop times, drug names, times and dosages

Documentation Required

Monitoring and recordkeeping requirements

Continuous monitoring and complete recordkeeping are required while the patient is in the operatory and until criteria for discharge to recovery are met. Monitoring must include assessment of oxygenation (including pulse oximetry and observation of mucosal color), continual observation of chest movement/ventilation and documentation of respirations, and circulation monitoring with blood pressure and heart rate documented pre-, intra-, and post-operatively. Maintain a complete anesthesia record documenting all physiologic parameters, drug names, administration times and dosages.

Continuous vital sign monitoring in the operatory until discharge criteria met
Oxygenation: pulse oximetry and observation of mucosal color
Ventilation: continual chest movement observation and documented respirations
Circulation: blood pressure and heart rate documented pre/intra/post-op
Complete anesthesia record with physiologic parameters, drug names, times and dosages

Billing Rule

Local anesthesia not separately billable generally

Administration of local anesthetic is considered inclusive of dental procedures and is generally not eligible for a separate benefit. Do not bill codes for local anesthesia separately unless the member's contract specifically allows coverage.

Affected codes: D9210, D9215
Do not bill separately unless member contract permits

Denial Risk

Regional/trigeminal block may be non-covered

Regional and trigeminal division block anesthesia may not be a covered service and may be denied unless the member's contract specifically provides coverage. Confirm coverage via the member's benefit contract or customer service prior to billing.

Affected codes: D9211, D9212
Potential denial unless contract specifies coverage

Documentation Required

Failed local anesthesia documentation

If deeper anesthesia is claimed because local anesthesia was ineffective, document failed attempts at local anesthesia administration and submit that documentation for review when requesting benefits for deeper sedation or general anesthesia.

Document and submit failed attempts of local anesthesia administration when claiming need for deeper anesthesia

Documentation Required

Pediatric sedation guidance

For pediatric patients, follow ADA/AAP/AAPD guidance: avoid preoperative oral sedatives for children 12 years and under except in extraordinary circumstances. Anthem follows contract and state-mandated ages for IV and inhalation anesthesia for benefit determinations; confirm applicable age limits in the member's contract.

Children 12 years and under: avoid preoperative oral sedatives except in extraordinary situations
Anthem follows contract/state age limits for IV and inhalation anesthesia — verify member contract

Background & Definitions

Background: The policy describes the accepted continuum of sedation and anesthesia levels — General Anesthesia, Deep Sedation, Intravenous Moderate (Conscious) Sedation/Analgesia and Minimal Sedation (Anxiolysis) — defined by effect on the central nervous system. It aligns practice with ADA/AAP/AAPD/ASA guidance and requires that dentists administering anesthesia be appropriately educated, trained and licensed. The policy emphasizes patient safety through continuous monitoring and complete documentation (oxygenation including pulse oximetry, ventilation/chest movement and respirations, circulation monitoring with blood pressure and heart rate pre/intra/post‑operative, and a complete anesthesia record), presence of additional individuals trained in Basic or Advanced Life Support when advanced anesthetics are used, and maintenance of emergency management capabilities (appropriate equipment, drugs, office protocols and staff responsibilities).

Term	Definition
General Anesthesia	Drug-induced loss of consciousness where patients are unarousable, may require assistance to maintain the airway and positive pressure ventilation due to depressed spontaneous breathing or neuromuscular depression; cardiovascular function might be impaired.
Deep Sedation/Analgesia	Drug-induced depression of consciousness in which a person is not easily aroused but responds purposefully after repeated or painful stimulation; airway assistance may be required and spontaneous breathing may be inadequate; cardiovascular function is generally preserved.
Intravenous Moderate (Conscious) Sedation/Analgesia	Drug-induced depression of consciousness to help a person feel relaxed and calm where no interventions are necessary to maintain the airway, spontaneous breathing is adequate and cardiovascular function is usually maintained; the person remains awake, able to follow directions and typically remembers little to nothing of the procedure.
Minimal Sedation (Anxiolysis)	A drug-induced state in which a person responds normally to verbal commands; cognitive function and coordination may be impaired, but airway reflexes, breathing and cardiovascular function are maintained.
Medically/Dentally Necessary	Services that are consistent with the member's diagnosis or condition and rendered to treat a life-threatening condition or pain, to treat injury/illness/infection related to the dentition, or to achieve dentition function consistent with prevailing community standards.

References: Cited guidance includes the American Society of Anesthesiologists (ASA) statements on the continuum/levels of sedation and dental office–based sedation/anesthesia, American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) guidance on pediatric monitoring and safety, American Dental Association (ADA) Guidelines for Use of Sedation and General Anesthesia by Dentists, and the American Dental Association CDT 2025 for current dental terminology and codes.

ALL of the following

Medical conditions necessitating general anesthesia must be supported by documentation submitted by the oral surgeon, dentist and/or physician administering the anesthesia.
Dentist administering anesthesia must remain in constant attendance with the patient until completion of the anesthesia procedure.
Time of general anesthesia begins when the dentist starts administering the sedative agent and non-invasive monitoring protocol; services complete when patient may be safely left under observation of trained personnel and the dentist may leave the operatory.
Office anesthesia in excess of 60 minutes for any dental or surgical procedure requires [policy indicates requirement but text is truncated; implies additional documentation/staffing/equipment obligations].
Policy statement incomplete in source document.

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

OpenPayer

Inhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Definitions

Revision History