CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2026 Policy)

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Defines coverage and medical necessity criteria for local anesthesia, regional/trigeminal block, nitrous oxide inhalation, intravenous moderate sedation, deep sedation/general anesthesia and related monitoring/documentation requirements for dental services. Applies to Anthem dental benefits and references state/contract-defined pediatric age limits.

Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2026 Policy)

Policy CodePolicy 09-201

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2026

Last ReviewOct 27, 2025

Next Review Date

Key ActionSubmit supporting medical documentation (radiographs, progress notes, operative report and complete anesthesia record) when medical conditions necessitate general anesthesia or moderate sedation.

SourceLink

POLICY UPDATE CHANGES

Policy revised with last review date 10/27/2025 and published 01/01/2026.

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CurrentAnthemPolicy 09-201

Inhalation and Local Anesthesia (2026 Policy)

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Policy Summary

PayerAnthem

PolicyInhalation and Local Anesthesia (2026 Policy)

Policy CodePolicy 09-201

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2026

Last ReviewOct 27, 2025

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Policy revised with last review date 10/27/2025 and published 01/01/2026.

Coverage Summary

This policy defines coverage and medical necessity criteria for inhalation and local anesthesia used in dental procedures, including nitrous oxide, intravenous moderate sedation, deep sedation/general anesthesia, and related monitoring and documentation requirements. Policy: Inhalation and Local Anesthesia (2026 Policy); Number: 09-201; Effective: 2026-01-01; Status: CURRENT.

Key policy facts

PayerAnthem

Policy Number09-201

Effective Date2026-01-01

Last Review2025-10-27

Next Review

Coverage stancemixed (conditional coverage for sedation/anesthesia; local anesthesia not separately reimbursed; regional/trigeminal may be non-covered)

Highlight> 60 minutes office anesthesia requires written rationale, radiographs, progress notes, operative report and a complete anesthesia record indicating start and stop times of incremental drug administration

Medical Necessity and Coverage Criteria

Local Anesthesia

Covered status and bundling

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, Intravenous Moderate Sedation/Analgesia, Non-Intravenous Conscious Sedation

Covered when performed with covered dental services and medical necessity criteria met

These procedures may be benefitted when appropriate in conjunction with covered dental services.

Codes

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	administration of deep sedation/general anesthesia - first 15-minute increment, or any portion thereof.
D9223	administration of deep sedation/general anesthesia - each subsequent 15-minute increment, or any portion thereof.
D9224	administration of general anesthesia with advanced airway - first 15-minute increment, or any portion thereof.
D9225	administration of general anesthesia with advanced airway - each subsequent 15-minute increment, or any portion thereof.
D9230	administration of nitrous oxide/administration of moderate sedation - intravenous.

1–10 of 17

1/2

ICD-10 (referenced)ICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions: see current CDT code book for details.

Provider Actions & Requirements

Documentation Required

Medical documentation for general anesthesia/moderate sedation

Submit supporting medical documentation from the oral surgeon, dentist and/or physician when medical conditions necessitate general anesthesia or moderate sedation. Documentation should include radiographs, progress notes, the operative report, and a complete anesthesia record.

Documentation Required

Failed local anesthesia

Document and submit records of failed attempts at local anesthesia administration when general anesthesia is being claimed because local anesthesia proved ineffective (examples: acute infection, anatomic variation, allergy).

Documentation Required

Monitoring records

Maintain continuous monitoring records and a complete anesthesia record that include oxygen saturation (pulse oximetry), observation/verification of respirations, blood pressure and heart rate (pre-, intra-, and post-operative), and the names, times and dosages of all drugs administered (local, IV, inhalation).

Background and Definitions

The policy outlines the accepted continuum of sedation depth and provides definitions for deep sedation/general anesthesia, intravenous moderate sedation, analgesia, and anxiolysis, emphasizing that the level of anesthesia is determined by the agent's effect on the central nervous system. It references guidance from the American Society of Anesthesiologists (ASA), American Dental Association (ADA), American Academy of Pediatrics (AAP), and American Academy of Pediatric Dentistry (AAPD) for definitions, monitoring and practice standards. For pediatric patients, while AAP/AAPD define a child as ages 0–21, the policy states that for benefit determination Anthem follows contract criteria and state-mandated ages for IV and inhalation anesthesia.

Definitions

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

Child (benefit purposes)Although AAP/AAPD define child as 0–21, for benefit purposes Anthem follows contract criteria and state mandated ages for IV and inhalation anesthesia for children.

Guideline sources: American Society of Anesthesiologists (ASA) statements on continuum of depth of sedation and office-based sedation/anesthesia; American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) guidelines and statements on pediatric monitoring and use of nitrous oxide; American Dental Association (ADA) Guidelines for the Use of Sedation and General Anesthesia by Dentists; and CDT 2026 (Current Dental Terminology) from the American Dental Association.

Revision History

2014-01-01published

Initial policy published.

2017-02-08revised

Revision (annual review/appropriateness and medical necessity updates).

2018-02-06revised

Revision (annual review).

Qualification criteria

Child with complex dental needs: The member is a child, up to the age defined by contract, with a dental condition that requires repairs of significant complexity (examples: multiple restorations, pulpal therapy, extractions, or combinations of procedures).
Physical/intellectual/medical compromise: The 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 include intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity).
Must be verified by appropriate medical documentation.
Behavioral issues: The member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs which 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.
Failed local anesthesia: The member for whom local anesthesia is ineffective (reasons such as acute infection, anatomic variations, or allergy).
Failed attempts of local anesthesia administration must be documented and submitted for review.
Extensive trauma: The member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.

Monitoring and Documentation Requirements

Conditions for safe administration and required records

Continuous operatory monitoring: A dentist, or at the dentist's direction, an appropriately trained individual must remain in the operatory during active dental treatment to monitor the patient's vital signs continuously until discharge criteria are met.

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

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

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

Complete anesthesia record: Documentation: maintain a complete anesthesia record including names of all drugs administered, times and dosages (local, IV, inhalation), and all physiological parameters monitored.

Emergency management: the dentist is responsible for adequacy of facility and staff, drug management, equipment, drugs and office protocol for emergency management related to administration of IV or inhalation drugs.