CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

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Defines medical necessity, documentation, monitoring and coverage considerations for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, IV and non-IV conscious sedation, and nitrous oxide when provided in conjunction with covered dental services; includes CDT code references and professional standards. Applies to dental and related medical benefit plans subject to contract and state mandates.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (annual review)

Effective DateJan 1, 2022

Last ReviewOct 20, 2021

Next Review Date

Key ActionWhen qualifying for general anesthesia or conscious sedation, submit medical documentation from the oral surgeon, dentist and/or physician supporting the medical condition; failed local anesthesia attempts must be documented for review

SourceLink

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CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

Inhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (annual review)

Effective DateJan 1, 2022

Last ReviewOct 20, 2021

Next Review Date

SourceLink

Coverage Summary & Scope

Defines medical necessity, documentation, monitoring and coverage considerations for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, IV and non‑IV conscious sedation, and nitrous oxide when provided in conjunction with covered dental services. Coverage is mixed — services are covered when medically/dentally necessary and when associated with underlying dental or medical benefits or required by a state mandate; applicability depends on the member's contract and state requirements.

Applies to dental and related medical benefit plans and includes CDT code references for informational use. Determinations depend on the underlying covered services, contractual language and any applicable state mandates; providers and reviewers should check member contract benefits to determine coverage.

Key thresholds and policy metadata

Effective date01/01/2022

Last review date10/20/2021

Policy number09-201

Office anesthesia duration documentation> 60 minutes requires written rationale/documentation explaining the necessity

Medical Necessity & Modality-specific Criteria

General medical necessity

Anesthesia services are covered when medically/dentally necessary and associated with covered dental or medical benefits, or when required by state mandate. Medical/Dental Necessity means services that meet ALL listed elements:

ALL of the following

Consistent with the member's diagnosis or condition
Rendered 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 dental function consistent with prevailing community standards
In accordance with generally accepted standards of dental practice (credible evidence, specialty society recommendations, views of recognized dentists)

Coverage for anesthesia modalities

Coverage determinations by modality when in conjunction with covered dental services or as required by state mandate:

CDT Code References (informational)

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

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Actions, Documentation & Billing Rules

Documentation Required

Support medical necessity with documentation

When qualifying for general anesthesia or conscious sedation, submit medical documentation from the oral surgeon, dentist and/or physician supporting the medical condition. Failed local anesthesia attempts must be documented for review.

Documentation Required

Maintain complete anesthesia record

Maintain an appropriate, complete anesthesia record that includes the names of all drugs administered, times of administration, dosages, all physiological parameters, and start and stop times of drug administration. Include associated x-ray images, progress notes and the operative report as applicable.

Drug names, times, dosages
All physiological parameters (monitoring)
Start and stop times of drug administration
Associated x-ray images, progress notes, operative report (as applicable)

Background and Definitions

This policy defines benefits and medical necessity standards for various anesthesia modalities used in dental practice, including local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non‑intravenous conscious sedation, and nitrous oxide. Coverage of these anesthesia services is generally available only in connection with underlying services that are covered under the dental or medical benefits plan or when services qualify by state mandate; therefore, applicability is determined by the member's contract and applicable state requirements.

The policy emphasizes patient safety and requires that dentists administering anesthesia be appropriately educated, trained and licensed, with continuous monitoring and documentation of vital signs, oxygenation, ventilation and circulation. An appropriate, complete anesthesia record must be maintained, and the dentist is responsible for drug management, facility/staff adequacy and emergency preparedness. When advanced anesthetics (IV or inhalation) are used, additional BLS‑trained personnel must be present and state‑required certifications (equipment inspection, sedation license, CPR) must be maintained.

Documentation requirements include a complete anesthesia record with drug names, administration times and dosages, physiological parameters, and start/stop times; for office anesthesia exceeding 60 minutes, a written rationale/documentation explaining the necessity is required. Coding references (CDT) are provided for informational purposes.

Medically/Dentally Necessary or Medical/Dental Necessity means Medical/Dental Services that are: consistent with the member's diagnosis or condition; rendered in response to a life‑threatening condition or pain, to treat an injury, illness or infection related to the dentition, or to achieve a level of dental function consistent with prevailing community standards; and in accordance with generally accepted standards of dental practice (based on credible scientific evidence, specialty society recommendations, and views of recognized dentists).

Revision History

01/01/2022revisedLatest

Policy marked as Revised; publish date 01/01/2022 and last review date 10/20/2021 (annual review).

10/20/2021revised

Last review date recorded as 10/20/2021 (annual review entry in revision history).

ALL of the following

Local anesthesia
- Local anesthesia (traditional, electronic, buffered, etc.) is considered inclusive of dental procedures and is not eligible for separate benefit unless plan specifically allows coverage
Regional/trigeminal block
- Regional and trigeminal division block anesthesia may not be a covered service
Deep sedation / General anesthesia / IV moderate sedation / Non-IV conscious sedation
- Qualification criteria (must meet ONE of the following)
  - Member is a child (up to age defined by contract) with a dental condition requiring repairs of significant complexity (e.g., multiple restorations, pulpal therapy, extractions, combinations of procedures)
  - Member has physical, intellectual, or medically compromising conditions for which local anesthesia cannot be expected to provide a successful result (examples: intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity) with verification by appropriate medical documentation
  - Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed and lack of treatment could result in pain, infection, tooth loss, or increased oral morbidity
  - Local anesthesia is ineffective for the member (e.g., acute infection, anatomic variations, allergy); failed attempts of local anesthesia must be documented and submitted for review
  - Member has sustained extensive oral-facial and/or dental trauma for which local anesthesia would be ineffective or compromised
- Medical conditions requiring general anesthesia must be supported by documentation from the oral surgeon, dentist and/or physician administering anesthesia
- Level of anesthesia is determined by documented effect on patient's CNS, not by route of administration
- Time of general anesthesia begins when the dentist starts administering sedative agent and non-invasive monitoring
- Dentist administering anesthesia must remain in constant attendance until completion and services are complete when patient may be safely left under observation of trained personnel
- Office anesthesia in excess of 60 minutes requires written rationale/documentation explaining necessity
Inhalation nitrous oxide
- Inhalation of nitrous oxide/analgesia may be benefitted when appropriate in conjunction with covered dental services
- Indications (nitrous oxide may be indicated for)
  - Ineffective local anesthesia administration
  - Treatment of dental anxiety
  - Special needs patients
  - Individuals who are uncooperative or behaviorally challenged
- Contraindications (nitrous oxide is contraindicated for, but not limited to)

Monitoring, documentation, and emergency requirements

Required monitoring, documentation, personnel and emergency preparedness for administration of advanced anesthetics:

ALL of the following

Appropriately trained individual must remain in the operatory during active treatment to continuously monitor vital signs until discharge criteria to recovery area are met
Monitoring must include observation of proper oxygenation (color of mucosa, continual evaluation); oxygen saturation by pulse oximetry is appropriate and necessary
Ventilation: chest movement and respirations must be continually observed and documented
Circulation: blood pressure and heart rate must be evaluated pre-op, intra-op and post-op and properly documented
An appropriate, complete anesthesia record must be maintained including drug names, times, dosages, and all physiological parameters; include start and stop times of drug administration
When advanced anesthetics (IV or inhalation) are used, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to dentist/oral surgeon
If required by the State, current equipment inspection certificate, sedation license and CPR certification are mandatory
Dentist responsible for drug management, adequacy of facility and staff, and emergency equipment/drugs/office protocol