CurrentBlue Cross Blue Shield - MainePolicy 09-201

Inhalation and Local Anesthesia (2022 Policy)

Defines medical necessity, appropriateness, monitoring, documentation, and coverage guidance for local anesthesia, regional/trigeminal blocks, intravenous and non-intravenous conscious sedation, deep sedation/general anesthesia, and inhalation nitrous oxide in dental settings for Anthem/BCBS Maine; includes CDT code list for informational billing purposes.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review Date

Key ActionSupport medical necessity with documentation from the oral surgeon, dentist and/or physician and maintain a complete anesthesia record including drug names, dosages, times, and physiological monitoring.

SourceLink

POLICY UPDATE CHANGES

Policy revised with annual review on 10/20/2021; committee review noted.

11CDT codes listed

4Anesthesia categories addressed

1Standalone local anesthesia billed separately (risk)

Coverage summary

This policy provides Anthem/BCBS Maine coverage guidance for dental anesthesia modalities including local, regional/trigeminal division block, intravenous and non-intravenous (conscious) sedation, deep sedation/general anesthesia, and inhalation nitrous oxide in dental settings. It defines medical/dental necessity criteria, monitoring and documentation expectations, and lists informational CDT billing codes. Coverage may vary by member contract and applicable state mandates, and the plan may require utilization review as specified by the member's benefits. Effective date: 2022-01-01.

Key facts

Policy number09-201

PayerBlue Cross Blue Shield - Maine (Anthem Health Plans of Maine, Inc.)

Effective date2022-01-01

Last review2021-10-20

StatusCURRENT

Coverage stancemixed

Medical necessity and coverage criteria

General medical necessity

Covered when ALL of the following are met:

ALL of the following

Service is consistent with the member's diagnosis or condition.
Service is in response to a life-threatening condition or pain; or to treat an injury, illness or infection related to the dentition; or to achieve a level of dentition function consistent with prevailing community standards.
Service is in accordance with generally accepted standards of dental practice (credible scientific evidence, specialty society recommendations, and views of recognized dentists).

Local anesthesia

Policy statements

Local anesthesia (traditional, electronic, buffered, etc.) is considered part of all dental procedures and is not eligible for a separate benefit unless a specific plan allows coverage.

Regional and trigeminal division block anesthesia

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

Intravenous (IV) conscious sedation / general anesthesia / deep sedation

To qualify for general anesthesia or conscious sedation benefit the member must satisfy ONE of the following:

ONE of

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, 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 and for which anesthesia can be expected to produce a superior result; requires appropriate medical documentation (conditions include but are not limited to intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity).
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs where deferral would likely result in pain, infection, tooth loss, or increased oral morbidity.
Local anesthesia is ineffective for the member (e.g., due to acute infection, anatomic variation, allergy); failed attempts at local anesthesia must be documented and submitted for review.

Inhalation nitrous oxide/analgesia

Coverage guidance and contraindications

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

Nitrous oxide may be indicated for ineffective local anesthesia administration, treatment of dental anxiety, special needs patients, and individuals who are uncooperative or behaviorally challenged.

Nitrous oxide is contraindicated for patients with severe respiratory compromise, patients with a history of stroke, first trimester pregnancy (potential teratogenic effects), hypotension and known cardiac conditions.

Monitoring and documentation

Conditions that must be met for anesthesia monitoring and records

A dentist or appropriately trained individual must remain in the operatory during active dental treatment to continuously monitor patient's vital signs until discharge criteria to recovery area are met; monitoring must include observation of proper oxygenation and pulse oximetry.

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

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

Documentation: a complete anesthesia record must be maintained including names of all drugs administered, times and dosages, and all physiological parameters with start and stop times of drug administration.

Dentist is responsible for emergency drug management, facility/staff adequacy and maintaining appropriate equipment, drugs and office protocol for emergency management.

Not covered and coverage limitations

Local anesthesia is considered inclusive to dental procedures and is not eligible for a separate benefit unless a specific plan allows coverage; separate billing may be denied. Regional and trigeminal division blocks may not be covered. Nitrous oxide may be appropriate for ineffective local anesthesia, dental anxiety, special needs, or uncooperative patients, but is contraindicated for patients with severe respiratory compromise, history of stroke, first trimester pregnancy, hypotension, and certain cardiac conditions. Coverage and contraindications are subject to contract and state-mandated variations.

CDT codes (informational)

CDT codes (informational only)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	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

1–10 of 11

1/2

Provider actions and billing rules

Documentation Required

Support medical necessity with documentation

Medical conditions that require general anesthesia or conscious sedation must be supported by documentation submitted by the oral surgeon, dentist and/or physician administering the anesthesia. Failed attempts at local anesthesia must be documented for review.

Documentation Required

Maintain complete anesthesia record

Maintain a complete anesthesia record including names of all drugs administered, times and dosages, and all physiological monitoring (oxygenation, pulse oximetry, blood pressure, heart rate, respirations) with start and stop times of drug administration.

Prior Authorization

Check benefit plan and potential review

Coverage of anesthesia services is available only in connection with underlying services covered under the dental/medical benefits plan or state mandate; verify the member's contract benefits and contact customer service to determine if utilization review is required.

Documentation Required

Monitoring and staff requirements

When IV or inhalation anesthesia is used to induce more profound levels, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist/oral surgeon. Where required by state, maintain current equipment inspection certificate, sedation license and CPR certification.

Denial Risk

Local anesthesia billed separately risk

Local anesthesia is considered inclusive to dental procedures and is not eligible for a separate benefit unless the specific plan allows coverage; separate billing for local anesthesia may be denied.

D9210
D9215

Background, definitions and evidence

This Anthem/BCBS Maine dental clinical policy describes appropriateness and medical necessity for anesthesia in dental practice and references national specialty guidance (ADA, AAP/AAPD, ASA and others). It emphasizes that dentists administering anesthesia must be appropriately educated, trained and licensed, and details monitoring and documentation requirements including continuous vital sign monitoring (oxygenation/pulse oximetry, ventilation observation, blood pressure and heart rate) and maintenance of a complete anesthesia record. The policy also notes that coverage and specific age/benefit determinations follow contract and state mandates.

Definitions

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

Child (clinical vs benefit)AAP/AAPD define child as ages 0–21 for clinical guidance; Anthem follows contract and state‑mandated ages for benefit determination of anesthesia for children.

Guideline references: American Dental Association (ADA); American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD); American Society of Anesthesiologists (ASA); American Association of Oral and Maxillofacial Surgeons (AAOMS) and other specialty guidance cited in the policy.

Operational thresholds

Thresholds

Office anesthesia duration requiring documentation> 60 minutes requires written rationale/documentation

Revision history

2021-10-20revisionLatest

Policy revised with annual review; committee review noted

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review Date

SourceLink

On This Page

Member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.

ALL of the following

Medical conditions that require general anesthesia must be supported by documentation submitted by the oral surgeon, dentist and/or physician administering the anesthesia.
The level of anesthesia is determined by the documented effect on the patient's central nervous system, not solely by the route of administration.
Time of general anesthesia begins when the dentist starts administering the sedative agent and non-invasive monitoring protocol.
Dentist administering the anesthesia must remain in constant attendance with the patient until completion of the anesthesia procedure; services are complete when the patient may be safely left under observation of trained personnel.
Office anesthesia in excess of 60 minutes requires written rationale/documentation explaining the necessity.>
> 60 minutes requires written rationale/documentation
When IV or inhalation are used to induce more profound levels of anesthesia, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist/oral surgeon; where required by state, current equipment inspection certificate, sedation license and CPR certification are mandatory.