CurrentBlue Cross Blue Shield - MainePolicy 09-201

Inhalation and Local Anesthesia (2021 Policy)

Defines medical necessity, documentation, monitoring and coverage stance for local anesthesia, regional/trigeminal block, inhalation nitrous oxide, conscious sedation (IV and non-IV), deep sedation/general anesthesia in dental settings; includes CDT code list and clinical indications/contraindications and operational requirements for office-based anesthesia.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyInhalation and Local Anesthesia (2021 Policy)

Policy CodePolicy 09-201

Change TypeClarified (Annual Review)

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain and submit documentation from the oral surgeon, dentist and/or physician supporting medical conditions that necessitate general anesthesia or conscious sedation; include rationale for coverage when local anesthesia is ineffective or for complex pediatric cases.

SourceLink

POLICY UPDATE CHANGES

Policy marked Revised with Annual Review on 11/12/2020 and 12/06/2020 (committee).

1Inclusive local anesthesia (no separate benefit)

2Services that may be non-covered (regional/trigeminal block)

5Indications listed for GA/sedation

Coverage Summary

This policy (Guideline #: 09-201) addresses dental anesthesia and sedation services including local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous moderate (conscious) sedation, non-intravenous conscious sedation and inhalation nitrous oxide. Status: CURRENT. Effective date: 2021-01-01. Last review: 2020-12-06. Coverage stance: mixed — the policy defines medical/dental necessity, monitoring and documentation requirements, and operational thresholds for office-based anesthesia in dental settings.

Thresholds and quick facts

Office anesthesia duration documentation thresholdWritten rationale required for procedures exceeding 60 minutes

Documentation required for durations >60 minProvide written rationale/documentation explaining necessity for office anesthesia in excess of 60 minutes

Policy noteAnesthesia services are covered only in conjunction with covered dental services or state mandate; check member contract

Counts from policy statsInclusive local anesthesia (no separate benefit): 1; Services that may be non-covered (regional/trigeminal block): 2; Indications listed for GA/sedation: 5

Medical Necessity Criteria

General Medically Necessary Criteria for Anesthesia Services

Anesthesia (deep sedation/general anesthesia, IV moderate sedation, non-IV conscious sedation, inhalation nitrous oxide) may be covered when performed in conjunction with covered dental services and medical necessity is supported.

ALL of the following

Service is performed in conjunction with underlying dental services that are covered under the member's dental or medical benefits plan or qualifies under state mandate
Medical necessity is supported by documentation from the oral surgeon, dentist and/or physician administering the anesthesia
Member meets ONE of the following
- Member is a child (age limit defined by contract) with a dental condition requiring repairs of significant complexity (examples: 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 (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 where postponing treatment would likely result in oral pain, infection, loss of teeth, or increased oral morbidity
- Local anesthesia is ineffective (e.g., due to acute infection, anatomic variations, allergy) and failed attempts of local anesthesia administration are documented
- Member has sustained extensive orofacial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised
When more advanced anesthetics (IV or inhalation) are used, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist/oral surgeon; if required by state, current equipment inspection certificate, sedation license and CPR certification are mandatory
Dentist administering anesthesia must remain in constant attendance until completion of anesthesia procedure and patient meets discharge criteria
Office anesthesia in excess of 60 minutes requires written rationale/documentation explaining necessityWritten rationale required for >60 minutes

Monitoring and Documentation Requirements

For all anesthesia/sedation modalities the following monitoring/documentation must be met:

A dentist or appropriately trained individual must remain in the operatory during active dental treatment to continuously monitor vital signs until discharge to recovery area

Monitoring must include observation of proper oxygenation (including mucosa color) and continuous evaluation; oxygen saturation by pulse oximetry is appropriate and necessary

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

Circulation monitoring: blood pressure and heart rate must be evaluated pre-op, intra-op and post-op and properly documented

A complete anesthesia record must be maintained including names of all drugs administered, time and dosages, and all physiological parameters with start and stop times

Local and Regional Anesthesia Coverage Positions

Local anesthesia is considered inclusive with all dental procedures and is not eligible for a separate benefit

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

Inhalation (Nitrous Oxide) Indications and Contraindications

Nitrous oxide may be covered when appropriate and in conjunction with covered dental services.

ALL of the following

Nitrous Oxide may be indicated for ONE of
- Ineffective local anesthesia administration
- Treatment of dental anxiety
- Special needs patients
- Individuals who are uncooperative or behaviorally challenged
Nitrous Oxide is contraindicated in patients with ONE of

Provider Actions & Billing Rules

Prior Authorization

Check benefits/contract

Verify member benefits and plan contract prior to scheduling or providing anesthesia services. Coverage for anesthesia depends on whether the underlying dental services are covered under the member's dental or medical benefits plan and may also be governed by state mandates. Utilization review or prior authorization requirements may apply per contract.

Documentation Required

Support medical necessity with documentation

Obtain and submit documentation from the oral surgeon, dentist and/or physician that supports the medical necessity for general anesthesia or conscious sedation. Required documentation should include the clinical rationale when local anesthesia is ineffective or for complex pediatric cases, relevant medical history/diagnoses, and operative/progress notes supporting the need for anesthesia.

Medical documentation of conditions that preclude successful treatment with local anesthesia (e.g., intellectual disability, cerebral palsy, epilepsy, severe cardiac problems)
Rationale for use of general anesthesia or conscious sedation (including failed attempts at local anesthesia, behavioral or clinical need)
Operative report and progress notes supporting the procedure complexity and need for anesthesia

Documentation Required

Maintain complete anesthesia record

Maintain a complete anesthesia record for all anesthesia modalities. The record must include the names of all drugs administered, times of administration, dosages, and all physiological monitoring parameters with start and stop times, along with the operative report and progress notes.

Affected codes: D9219, D9222, D9223, D9230, D9239, D9243, D9248

Documentation Required

Monitor and document vitals

Continuously monitor and document oxygenation, ventilation and circulation during anesthesia/sedation. Monitoring must be performed by the dentist or an appropriately trained individual and documented until the patient meets discharge criteria.

Oxygenation: observe mucosal color and continuous evaluation; pulse oximetry is appropriate and necessary
Ventilation: continuous observation of chest movement; respirations verified and documented
Circulation: blood pressure and heart rate evaluated pre-op, intra-op and post-op and documented

Billing Rule

Local anesthesia not separately reimbursable

Do not bill separately for local anesthesia when provided in conjunction with operative or surgical dental procedures; local anesthesia is considered inclusive with all dental procedures.

Affected codes: D9215, D9210

Denial Risk

Regional/trigeminal block may be non-covered

Regional and trigeminal division block anesthesia may not be covered by the plan and claims for these services can be denied if not covered by the member contract or if medical necessity is not met. Confirm coverage under the member's contract and applicable state mandates.

Affected codes: D9211, D9212
Coverage subject to member contract and state mandates

Documentation Required

Duration justification

Provide written rationale/documentation to justify office-based anesthesia that exceeds 60 minutes. Documentation should explain the medical necessity for the extended duration.

Threshold: written rationale required for procedures exceeding 60 minutes

Background and Guideline References

This clinical policy aligns with guidance from the American Dental Association (ADA), American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD), the American Society of Anesthesiologists (ASA) and specialty societies (see reference list). It affirms that dentists administering anesthesia should be appropriately educated, trained and licensed and follows specialty recommendations for monitoring and management of pediatric and adult patients during and after sedation. Coverage for anesthesia services depends on the member's dental or medical benefits plan and any applicable state mandates; a determination of medical necessity does not guarantee a payable benefit under a particular plan or contract.

Evidence / Guideline references

Guideline referencesADA; AAP/AAPD; ASA; AAOMS

Source detailsReferences list includes ADA guidelines, AAP/AAPD pediatric sedation guidelines, ASA contact, and AAOMS Parameters of Care

Policy citationGuidelines cited in policy support monitoring, training, and use of anesthesia modalities in dental settings

Medically/Dentally Necessary means services that are consistent with the member's diagnosis or condition, provided in response to a life‑threatening condition or pain, to treat an injury/illness/infection related to the dentition, or to achieve dentition function consistent with prevailing community standards.

OpenPayer

Inhalation and Local Anesthesia (2021 Policy)

Coverage Summary

Medical Necessity Criteria

Coding (CDT)

Provider Actions & Billing Rules

Background and Guideline References

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