CurrentBlue Cross Blue Shield - NevadaPolicy 09-201

Inhalation and Local Anesthesia (2022 Policy)

Defines medical necessity, appropriateness, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal blocks, intravenous conscious sedation, non-intravenous sedation, inhalation nitrous oxide, and general/deep sedation for dental services across Anthem/BCBS plans (dental/medical benefits and state mandates may affect coverage). Includes CDT code list for reference.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeRevised (annual review)

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain and submit supporting medical documentation when general anesthesia or conscious sedation is used due to medical conditions.

SourceLink

POLICY UPDATE CHANGES

Document marked 'Revised' with last review date 10/20/2021 and publish date 01/01/2022 (annual review).

11CDT codes listed

>=1Documentation requirements (monitoring items listed)

60Duration threshold requiring justification

Coverage Summary

This coverage guideline (Policy #: 09-201) addresses dental anesthesia modalities including local, regional/trigeminal block, intravenous conscious (moderate) sedation, non-intravenous conscious sedation, inhalation nitrous oxide/analgesia, and deep/general anesthesia. Status: CURRENT. Effective date: 01/01/2022; Last review: 10/20/2021 (annual committee review). Scope: defines medical necessity, appropriateness, monitoring and documentation requirements, provider qualifications, and coverage conditions for anesthesia services across Anthem/BCBS plans, noting that coverage may depend on whether services are covered under the member's dental or medical benefits plan or required by state mandate.

Medical-Necessity Criteria

General Medical Necessity

Anesthesia services are covered when ALL of the following are met:

ALL of the following

Anesthesia services are provided in connection with underlying dental services that are covered under the member's dental or medical benefits plan or qualify based on state mandate
Services meet generally accepted standards of dental care and are medically/dentally necessary (consistent with diagnosis/condition; in response to life-threatening condition or pain; to treat injury/illness/infection related to dentition; or to achieve functional dentition consistent with community standards)
Dentist administering anesthesia is appropriately educated, trained and licensed; additional staff trained in Basic Life Support for Healthcare Providers present when IV or inhalation anesthetics are used as required
When general anesthesia or conscious sedation is used due to medical conditions, medical documentation from a physician must support necessity
Monitoring and documentation requirements are met (continuous monitoring of vital signs/oxygenation/pulse oximetry, ventilation observation, circulation monitoring pre/intra/post-operative, complete anesthesia record including drug names/doses/times and physiologic parameters)

Intravenous Conscious Sedation / General Anesthesia - Coverage Criteria

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

Clinical indications

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, 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) and is supported by appropriate medical documentation
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs where postponement would likely result in pain, infection, tooth loss, or increased oral morbidity
Local anesthesia is ineffective for the member due to acute infection, anatomic variations, or allergy; failed attempts at local anesthesia must be documented and submitted for review

Local Anesthesia

Coverage position:

Administration of local anesthesia (traditional, electronic, buffered, etc.) is considered inclusive to 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

Coding (CDT)

CDT procedure codes (informational list included)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

Inclusion of a procedure or diagnosis code in the CDT list is informational only and does not guarantee coverage or reimbursement; verify the member's contract benefits at the time of service to determine coverage.

Provider Actions & Billing Impact

Prior Authorization

Pre-review for coverage determination

Verify the member's contract benefits and any applicable state mandates before providing anesthesia services. Coverage depends on whether the underlying dental services are covered by the member's dental or medical plan or state mandate. The plan may require utilization review or preauthorization for anesthesia services; contact the customer service number on the member's ID card to determine if pre-review/preauthorization is required.

Documentation Required

Medical support for anesthesia necessity

When general anesthesia or conscious sedation is used because of the member's medical conditions, obtain and submit supporting medical documentation from the oral surgeon, dentist and/or the physician administering the anesthesia to justify medical necessity.

Documentation Required

Anesthesia record and monitoring documentation

Maintain a complete anesthesia record and continuous physiologic monitoring. The anesthesia record must include names of all drugs administered, times of administration, and dosages (including local anesthetics and other anesthetic drugs) and start/stop times. Continuous monitoring and documentation must include oxygenation (including pulse oximetry), ventilation (observation of chest movement and respirations), and circulation (blood pressure and heart rate pre-operative, intra-operative and post-operative).

Documentation Required

Failed local anesthesia documentation

If claiming anesthesia because local anesthesia was ineffective, document failed attempts and the reasons (for example, acute infection, anatomic variation, or allergy). Submit documentation of failed local anesthesia attempts for review to support the claim for general anesthesia or conscious sedation.

Denial Risk

Separate benefit denial risk for local anesthesia

Local anesthesia (e.g., D9210, D9215) is generally considered inclusive to dental procedures and not eligible for separate benefit unless a specific plan allows coverage. Claims seeking separate payment for local anesthesia risk denial.

Relevant CDT examples: D9210, D9215

Billing Rule

Coding informational only

Inclusion of a CDT procedure code in the document is informational only and does not guarantee coverage or reimbursement. Always verify the member's contract benefits at the time of service to determine coverage.

Background & Definitions

Background: This clinical guideline describes the medical necessity framework and purpose for anesthesia modalities used in dental practice, emphasizing safe and effective use, appropriate monitoring (continuous observation of oxygenation/pulse oximetry, ventilation, circulation and complete anesthesia records), provider qualifications and staffing (dentists must be appropriately educated, trained and licensed; additional Basic Life Support–trained personnel required for IV/inhalation anesthetics), and documentation requirements. It notes that coverage for anesthesia services is generally available only when the underlying dental services are covered under the member's dental or medical plan or when required by state mandate, and that utilization review or plan-specific requirements may apply.

Term	Definition
Medically/Dentally Necessary	Services consistent with diagnosis/condition; in response to a life‑threatening condition or pain; to treat injury/illness/infection related to the dentition; or to achieve functional dentition consistent with community standards.
Child (clinical reference)	AAP/AAPD define child as ages 0-21; for benefit purposes Anthem follows contract and state‑mandated ages for IV and inhalation anesthesia.

Evidence/References: guideline citations include the American Dental Association (ADA) guidelines on sedation and anesthesia, American Academy of Pediatrics (AAP) / American Academy of Pediatric Dentistry (AAPD) monitoring and management guidance, American Society of Anesthesiologists (ASA) materials, American Association of Oral and Maxillofacial Surgeons (AAOMS) parameters of care, and related published guidelines on sedation and monitoring.

Revision History

01/01/2022publishLatest

Policy published (Dental Clinical Policy publish date 01/01/2022).

10/20/2021review

Annual review by Committee (document marked 'Revised' with last review date 10/20/2021).

12/06/2020review

Annual review by Committee (revision entry 12/06/2020).

11/12/2020review

Annual review by Committee (revision entry 11/12/2020).

02/06/2018revision

Revision noting updates to appropriateness and medical necessity (revision entry 02/06/2018).

02/08/2017revision

Revision recorded on 02/08/2017 (revision history).

01/01/2014initial

Initial version published 01/01/2014 (revision history indicates initial 1/1/14).