CurrentAnthemPolicy N/A

Dental Clinical Policy - Therapeutic Parenteral Drug Administration

Defines Anthem's clinical review criteria and documentation requirements for therapeutic parenteral drug administration in dental care (IV/IM/SC/intradermal), clarifies non-covered or non-benefitted uses (cosmetic, sedative/anesthetic/reversal agents), and lists applicable CDT codes for informational purposes. It is a clinical guideline used for utilization review and benefit determination subject to contract terms.

Policy Summary

PayerAnthem

PolicyDental Clinical Policy - Therapeutic Parenteral Drug Administration

Policy CodePolicy N/A

Change TypeRevised (annual review)

Effective Date01/01/2022

Next Review DateN/A

Key ActionSubmit the name and dosage of the medication administered for benefit consideration; retain and provide clinical chart notes and narrative upon request to support medical/dental necessity.

SourceLink

POLICY UPDATE CHANGES

Policy marked as Revised with last review date 10/30/2021 and publish date 01/01/2022.

2CDT Codes Listed

3Non-benefitted categories

5Documentation items

Coverage Summary

Defines Anthem's clinical review criteria and documentation requirements for therapeutic parenteral drug administration in dental care (intravenous, intramuscular, subcutaneous, intradermal) and clarifies non-covered/non-benefitted uses such as cosmetic indications and administration of sedative/anesthetic/reversal agents. This guideline is used for utilization review and benefit determination and is applied subject to the member's contract terms and coverage rules. Effective date: 01/01/2022. Last review date: 10/30/2021.

Medically Necessary / Review Criteria

Covered when ALL of the following are met:

Medically Necessary

Route of administration: Parenteral administration is via intravenous, intramuscular, subcutaneous or intradermal route
Any technique in which the route of administration is intravenous, intramuscular, subcutaneous or intradermal.
Therapeutic indication: Administration is for therapeutic indications: antibiotics, steroids, anti-inflammatory drugs or other therapeutic medications where indicated to improve surgical healing, reduce pain and/or infection
Therapeutic parenteral drug administration may be single or multiple administrations.
Medication details submitted: The name and dosage of the medication administered are submitted for benefit consideration
Clinical documentation: Clinical chart notes and narrative may be submitted/requested to explain the rationale for the medication
Standards of practice: Services meet generally accepted standards of dental practice (based on credible peer-reviewed dental evidence, specialty society recommendations, and views of recognized dentists practicing in the relevant clinical area)
Non-convenience/cosmetic/cost: Service is not primarily for the convenience of patient or dentist, is not cosmetic, and is not more costly than an alternative service

Not Benefitted / Not Covered

The following ARE NOT benefitted under the dental plan:

Not benefitted

Experimental/Investigational/Unproven: Procedures that are experimental, investigational or unproven are not benefitted
Cosmetic use: Drug administration for cosmetics is not a benefitted service
Sedative/anesthetic/reversal agents: Therapeutic parenteral drug administration should not be used to report administration of sedative, anesthetic or reversal agents

Denial Risk

Non-benefitted uses will not be covered

Claims for experimental/investigational/unproven procedures, cosmetic drug administration, or administration reported as sedative/anesthetic/reversal agents risk denial as non-benefitted.

Cosmetic uses (drug administration for cosmetics is not benefitted)
Sedative/anesthetic/reversal agents (therapeutic parenteral codes should not be used to report these)
Experimental, investigational, or unproven procedures

Provider Documentation & Billing Actions

Documentation Required

Medication name and dosage required

Submit the name and dosage of the medication administered for benefit consideration.

D9610
D9612

Documentation Required

Clinical chart notes may be requested

Clinical chart notes and narrative may be requested to explain the rationale for the medication; retain and provide upon request to support medical/dental necessity.

Denial Risk

Non-benefitted uses will not be covered

Claims for experimental/investigational/unproven procedures, cosmetic drug administration, or administration reported as sedative/anesthetic/reversal agents risk denial as non-benefitted.

Cosmetic uses (drug administration for cosmetics is not benefitted)
Sedative/anesthetic/reversal agents (therapeutic parenteral codes should not be used to report these)
Experimental, investigational, or unproven procedures

Coding

Informational CDT Codes (applicable to this document)mixed

D9610	Therapeutic parenteral drug, single administration
D9612	Therapeutic parenteral drugs, two or more administrations, different medications

Reference - ICD-10-CMICD-10

See CDT code book

IDC-10 CM Diagnoses for Dental Diseases and Conditions: See current CDT code book for details

The listed CDT and diagnostic code references are provided for informational purposes only; inclusion of a code does not guarantee member coverage or provider reimbursement and benefit determination remains subject to the member's contract and required documentation. ICD-10 diagnoses and details should be obtained from the current CDT/ICD resources as noted in the code references.

Background and Evidence

This guideline supports utilization review of therapeutic parenteral drug administration in dental settings (single or multiple administrations via IV, IM, SC or intradermal) to ensure services meet generally accepted standards of dental practice and contractual benefit rules. It excludes drug administration reported for sedative, anesthetic or reversal agents and excludes cosmetic uses. The purpose is to define review criteria and documentation requirements (medication name/dosage, chart notes) to assess medical/dental necessity for therapeutic medications such as antibiotics, steroids and anti-inflammatories.

Key references include the AAOMS White Paper on Opioid Prescribing (2017) and a non-inferiority randomized controlled trial on antibiotics in third molar extraction (Natl Maxillofac Surg 2014) as cited in the guideline.

Definitions

Parenteral administrationAny technique in which the route of administration is intravenous, intramuscular, subcutaneous or intradermal.

Generally accepted standards of dental practiceStandards based on credible scientific evidence in peer-reviewed dental literature, specialty society recommendations/criteria, and views of recognized dentists practicing in the relevant clinical area.