CurrentBlue Cross Blue Shield - NevadaPolicy 09-201

Inhalation and Local Anesthesia (2021 Policy)

Defines medical necessity, coverage conditions, monitoring/documentation, and coding guidance for local anesthesia, regional/trigeminal blocks, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide in dental settings for Blue Cross Blue Shield - Nevada.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyInhalation and Local Anesthesia (2021 Policy)

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit supporting medical/dental documentation (including failed local anesthesia attempts and complete anesthesia record with drug names, times, dosages and physiologic monitoring) and verify member benefit/plan review prior to billing.

SourceLink

POLICY UPDATE CHANGES

Annual review completed 12/06/2020; no clinical policy statement changes indicated in revision history.

1Local anesthesia reimbursement status (inclusive)

1Regional/trigeminal block coverage (may not be covered)

1Deep sedation/general anesthesia (conditional coverage)

1Nitrous oxide (conditional coverage)

Coverage Summary

Overview: This Anthem dental anesthesia coverage criteria (Policy #09-201, effective 01/01/2021) defines medical necessity and appropriateness standards for local anesthesia, regional/trigeminal blocks, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide in dental settings. The policy affirms that anesthesia services are to be used safely and only by appropriately trained/licensed providers and requires monitoring and documentation consistent with the guideline.

Scope and payer stance: Coverage stance is mixed/conditional — anesthesia services may be covered when medically/dentally necessary and in conjunction with covered underlying dental or medical services or when required by state mandate. Plan/contract language and state mandates govern whether a service determined to be medically necessary is a covered benefit; verification of the member's dental and medical benefits is advised and utilization review may be applied.

Surface thresholds and quick facts

Office anesthesia > 60 minutesRequires written rationale/documentation explaining necessity

Local anesthesia statusConsidered inclusive with all dental procedures and not eligible for separate benefit

Regional/trigeminal blocksMay not be a covered service; verify coverage before billing

Deep sedation/general anesthesiaMay be benefitted when appropriate in conjunction with covered dental services; medical documentation required to support need

Nitrous oxide (inhalation)May be benefitted when appropriate in conjunction with covered services; indicated for ineffective local anesthesia, anxiety, special needs, uncooperative patients; has listed contraindications

Medical Necessity and Qualification Criteria

General medical necessity

Anesthesia services are covered when medically/dentally necessary and in conjunction with covered underlying dental or medical services, or as required by state mandate.

ALL of the following

Services are consistent with the member's diagnosis or condition
Services are in response to a life-threatening condition or pain
Services are to treat an injury, illness or infection related to the dentition
Services achieve a level of function consistent with prevailing community standards for the diagnosis or condition

Coding

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	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 & Billing Guidance

Documentation Required

Medical documentation for general anesthesia/ conscious sedation

Submit supporting documentation from the oral surgeon, dentist, and/or physician to justify medical conditions requiring general anesthesia or conscious sedation. Include documentation of failed local anesthesia attempts when claimed. Maintain a complete anesthesia record with drug names, administration times, dosages, and physiologic monitoring.

Physician or oral surgeon notes
Dentist operative/progress notes
Complete anesthesia record (drug names, times, dosages)

Documentation Required

Monitoring documentation

Continuously monitor and document vital signs during anesthesia. Document oxygenation (including color of mucosa and oxygen saturation/pulse oximetry), ventilation (observe chest movement and verify respirations), and circulatory parameters (blood pressure and heart rate) pre-operatively, intra-operatively and post-operatively. Retain monitoring records as part of the anesthesia record.

Background and Guideline References

Guideline reliance: This policy explicitly references and relies upon recognized specialty and professional guidance, including the American Dental Association (ADA) guidance on sedation and anesthesia, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) pediatric sedation monitoring guidelines, the American Society of Anesthesiologists (ASA) resources, and AAOMS parameters of care and related position statements.

Operational note: Plan coverage remains subject to contract and state mandates; the plan performs review of anesthesia services to ensure they meet contractual and generally accepted standards of dental care. Utilization review, prior review, and documentation requirements (including continuous monitoring, pulse oximetry, blood pressure/heart rate documentation, and a complete anesthesia record) may be applied to determine benefit eligibility.

Definitions

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

ChildAAP/AAPD define child as ages 0–21, but Anthem follows contract and state‑defined ages for benefit purposes

Revision History

11/12/2020annual_review

Annual Review completed 11/12/2020 by Committee; no material clinical policy statement changes indicated in revision history.

12/06/2020annual_reviewLatest

Annual Review completed 12/06/2020 by Committee; no clinical policy statement changes indicated in revision history.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyInhalation and Local Anesthesia (2021 Policy)

Policy CodePolicy 09-201

Change TypeClarified (annual review)

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

Deep sedation/general anesthesia/IV and non-IV conscious sedation - qualifying criteria

Member must satisfy ONE of the following to qualify for general anesthesia or conscious sedation benefit (documentation required).

ONE of

Member is a child up to the age defined by contract with a dental condition requiring complex repairs (e.g., multiple restorations, pulpal therapy, extractions or combinations)
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) and condition is verified by medical documentation
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs where lack of treatment could lead to pain, infection, tooth loss, or increased oral morbidity
Local anesthesia is ineffective (e.g., due to acute infection, anatomic variations or allergy); failed attempts must be documented and submitted for review
Member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised

Regional and trigeminal division block anesthesia

Coverage stance for regional/trigeminal blocks

Regional and trigeminal block anesthesia may not be a covered service

Local anesthesia

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

Inhalation nitrous oxide/analgesia

Nitrous oxide may be benefitted when appropriate in conjunction with covered dental services; indicated and contraindicated conditions listed.

ALL of the following

Indications - ONE of
- Ineffective local anesthesia administration
- Treatment of dental anxiety
- Special needs patients
- Individuals who are uncooperative or behaviorally challenged
Contraindications - ONE of
- Patients with severe respiratory compromise
- Patients with a history of stroke
- First trimester pregnancy (potential teratogenic effects)
- Hypotension and known cardiac conditions

Operational/monitoring requirements

Monitoring and documentation required for anesthesia administration.

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

Monitoring must include observation of proper oxygenation (mucosa color), continuous oxygen saturation by pulse oximetry as appropriate

Ventilation: chest movement must be continually observed; 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

An appropriate, complete anesthesia record must be maintained with drug names, administration times, dosages, and all physiological parameters

Emergency management: dentist responsible for drug management, facility adequacy, staff, equipment, drugs and protocols for emergencies related to IV or inhalation drugs

Time of general anesthesia begins when dentist starts administering sedative agent and non-invasive monitoring; dentist must remain in constant attendance until completion

Services considered complete when patient may be safely left under observation of trained personnel and dentist may safely leave the operatory

Office anesthesia in excess of 60 minutes requires written rationale/documentation explaining necessity> 60 minutes requires written rationale/documentation

Pre-, intra-, and post-operative blood pressure and heart rate
Continuous pulse oximetry/oxygen saturation
Ventilation assessment (chest movement, recorded respirations)

Prior Authorization

Review required per plan/contract

Anesthesia services are subject to plan/contract review and may require prior review to determine whether they meet contractual benefit and medical necessity requirements. Verify coverage by checking both the member's dental and medical benefits prior to providing or billing anesthesia services.

Check member dental and medical benefits to determine coverage

Billing Rule

Local anesthesia not separately reimbursable

Local anesthesia is considered inclusive with dental procedures and is not eligible for a separate benefit. Do not bill separately for local anesthesia when rendered with other dental procedures.

Affected codes: D9215, D9210

Billing Rule

Regional/trigeminal block may be non-covered

Regional and trigeminal division block anesthesia may not be a covered service under the plan. Verify coverage before performing or billing these procedures.

Affected codes: D9211, D9212

Documentation Required

Anesthesia time and attendance

Document start and stop times of drug administration for time-based anesthesia services. The dentist must remain in constant attendance until completion of the anesthesia procedure and safe handoff to trained personnel. Maintain attendance and time documentation in the anesthesia record.

Time-based codes: D9222, D9223, D9239, D9243