CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

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Defines medical necessity, monitoring, documentation, and coverage conditions for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and nitrous oxide when provided in conjunction with covered dental services; notes state/contract variation and that local anesthesia is generally bundled.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (annual review)

Effective DateJan 1, 2023

Last ReviewNov 11, 2022

Next Review Date

Key ActionSubmit supporting medical documentation from the oral surgeon, dentist and/or physician when medical conditions justify general anesthesia or conscious sedation; include rationale for anesthesia modality.

SourceLink

POLICY UPDATE CHANGES

Policy status indicated as Revised with last review date 11/11/2022 and publish date 01/01/2023.

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CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

Inhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (annual review)

Effective DateJan 1, 2023

Last ReviewNov 11, 2022

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Policy status indicated as Revised with last review date 11/11/2022 and publish date 01/01/2023.

Coverage Summary

Scope: This policy defines medical/dental necessity, monitoring, documentation, and coverage conditions for dental anesthesia modalities — including local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide — when provided in conjunction with covered dental or medical services or when required by state mandate. Coverage is conditional on the underlying service being a covered benefit per the member's contract or applicable state requirements.

Coverage stance: Mixed — local anesthesia is generally bundled and considered inclusive to procedures and is not eligible for a separate benefit unless a specific plan allows it; regional/trigeminal block anesthesia may not be covered; deep sedation/general anesthesia, conscious sedation, and nitrous oxide may be covered when performed with covered dental services and when medical/dental necessity criteria are met.

Medical Necessity and Coverage Criteria

General coverage framework

Coverage of anesthesia services is available only in connection with underlying covered dental or medical services or when required by state mandate; benefits follow medical/dental necessity and contract terms.

ALL of the following

Anesthesia services must be provided in conjunction with underlying dental services that are covered under the member's dental or medical benefits plan or qualify based on state mandate
Services must meet Medical/Dental Necessity: consistent with member diagnosis or condition; rendered in response to life‑threatening condition or pain; to treat dentition‑related injury/illness/infection; or to achieve level of function consistent with prevailing community standards
Dentist administering anesthesia must be appropriately educated, trained and licensed; when advanced anesthetics (IV or inhalation) are used additional individuals trained in Basic Life Support for Healthcare Providers must be present
If required by state, maintain equipment inspection certificate, sedation license and CPR certification

Local anesthesia

Coverage determination for local anesthesia

Local anesthesia (traditional, electronic, buffered, etc.) is considered inclusive 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

Deep sedation/general anesthesia and conscious sedation

These procedures may be covered when performed in conjunction with covered dental services and when medical necessity criteria are met.

ALL of the following

Performed in conjunction with covered dental services
Medical conditions requiring general anesthesia must be supported by documentation from the oral surgeon, dentist and/or physician administering the anesthesia
Member must satisfy ONE of the following
- The member is a child (up to the age defined by contract) with a dental condition requiring repairs of significant complexity (e.g., multiple restorations, pulpal therapy, extractions, combinations of procedures)
- The member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia cannot be expected to provide a successful result and which under anesthesia can be expected to produce a superior result (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity) and verified by appropriate medical documentation

Inhalation nitrous oxide/analgesia

Nitrous oxide may be covered in conjunction with covered dental services when indicated; contraindications noted.

ALL of the following

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

Coding (CDT anesthesia and sedation codes)

CDT anesthesia and sedation codes (informational)CPT

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 12

1/2

Provider Actions & Billing Impact

Prior Authorization

Potential prior review for anesthesia services

Plan performs review of anesthesia services per contractual requirements. Check the member's dental and medical benefit contract to determine whether a prior review or prior authorization is required before providing anesthesia services.

Documentation Required

Medical documentation for general anesthesia or conscious sedation

Submit supporting medical documentation from the oral surgeon, dentist and/or physician when general anesthesia or conscious sedation is justified. Include the clinical rationale for the chosen anesthesia modality and documentation that the member meets medical necessity criteria.

Documentation Required

Failed local anesthesia documentation

Background

Background: This policy focuses on appropriateness and medical/dental necessity criteria for dental anesthesia modalities and enforces minimum monitoring and documentation standards. It requires that anesthesia services be provided only in conjunction with underlying covered dental or medical services or when qualified by state mandate, and that benefits follow medical/dental necessity and contract terms.

Provider requirements and safety: Dentists administering anesthesia must be appropriately educated, trained and licensed; when advanced anesthetics (IV or inhalation) are used, additional individuals trained in Basic Life Support for Healthcare Providers must be present. If required by state law, providers must maintain equipment inspection certificates, sedation licenses and current CPR certification.

Monitoring & documentation standards: A dentist or appropriately trained individual must remain in the operatory during active treatment to continuously monitor vital signs until discharge criteria are met. Monitoring must include observation of oxygenation (including mucosal color), pulse oximetry as appropriate, continual observation of chest movement and documented respirations, and pre/intra/postoperative evaluation and documentation of blood pressure and heart rate. A complete anesthesia record must list drugs administered, times, dosages and all physiologic parameters; office anesthesia exceeding 60 minutes requires written rationale and full supporting documentation (x-rays, progress notes, operative report and complete anesthesia record).

Revision History

2022-11-11revised

Annual review completed; policy status indicated as Revised with last review date 11/11/2022.

2023-01-01revisedLatest

Policy published/effective 01/01/2023 following the annual review; no material clinical change documented in this revision.