CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

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Defines clinical indications, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal block, inhalation (nitrous oxide), intravenous and non-intravenous conscious sedation, deep sedation and general anesthesia in dental settings. Applies to office-based dental anesthesia and specifies when services may be benefitted in conjunction with covered dental services.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2025

Last ReviewOct 31, 2024

Next Review DateN/A

Key ActionSubmit required medical documentation (radiographs, progress notes, operative report and a complete anesthesia record with start/stop times and dosages) to support general anesthesia or conscious sedation benefits.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised; last review date 10/31/2024 with publish date 01/01/2025.

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CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

Inhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2025 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2025

Last ReviewOct 31, 2024

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised; last review date 10/31/2024 with publish date 01/01/2025.

Coverage Summary

Overview: This policy (Guideline #09-201) defines clinical indications, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal block, inhalation (nitrous oxide), intravenous and non-intravenous conscious sedation, deep sedation and general anesthesia in dental settings. Status: CURRENT (Revised). Last review: 10/31/2024. Effective / Publish date: 01/01/2025.

Summary: Deep Sedation/General Anesthesia, Intravenous Moderate (Conscious) Sedation/Analgesia and Non-Intravenous Conscious Sedation may be benefitted when provided in conjunction with covered dental services and when documentation supports applicable criteria. Benefit application follows the member's contract terms and any state-specific pediatric age definitions; documentation from the oral surgeon, dentist and/or physician (e.g., radiographs, progress notes, operative report and a complete anesthesia record) must be submitted for review to establish medical necessity.

Key facts / Summary

Effective2025-01-01

Last review2024-10-31

Policy09-201

Coveragemixed

Medically Necessary / Benefitted Criteria

Medically Necessary / Benefitted Anesthesia Services

Deep Sedation/General Anesthesia, Intravenous Moderate (Conscious) Sedation/Analgesia, Non-Intravenous Conscious Sedation may be benefitted when appropriate in conjunction with covered dental services and when documentation supports one of the following:

ANY 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 or 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).
Must be verified by appropriate medical documentation.
The member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed and where lack of treatment could result in oral pain, infection, tooth loss, or increased oral morbidity.

Local Anesthesia Coverage Position

Local Anesthesia

Coverage position for local anesthesia in dental procedures:

Local anesthetic administration (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.

Billing Rule

Local anesthesia not separately billable generally

Administration of local anesthesia is considered inclusive of dental procedures and is not eligible for a separate benefit unless the member's specific plan allows coverage. Providers should check member contract to determine whether codes for local anesthesia may be billed separately.

D9210
D9215

Regional & Trigeminal Division Block Anesthesia

Regional and Trigeminal Division Block Anesthesia

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

Inhalation (Nitrous Oxide) Coverage & Contraindications

Administration, Monitoring & Provider Qualifications

Documentation Required

Medical documentation required for general anesthesia/conscious sedation

Medical conditions requiring general anesthesia or conscious sedation must be supported by documentation from the oral surgeon, dentist and/or physician administering the anesthesia. Required documentation to submit for review includes all associated radiographs, progress notes, the operative report, and a complete anesthesia record indicating start and stop times of incremental drug administration.

Documentation Required

Monitor and record physiologic parameters

Continuously monitor and document oxygenation (including mucosa color), pulse oximetry, chest movement/respirations, and circulation (blood pressure and heart rate) pre-operatively, intra-operatively and postoperatively. Maintain a complete anesthesia record that lists all drugs administered with times and dosages and all physiological parameters.

Prior Review / Authorization & Documentation

Prior Authorization

Prior review may be required for general anesthesia

Prior review may be required for general anesthesia or conscious sedation; required medical documentation must be submitted for review. Final coverage determinations are governed by the member's plan/contract terms.

Documentation Required

Failed local anesthesia documentation for coverage

Failed attempts at local anesthesia must be documented and submitted for review to support the use of alternative anesthesia methods (for example, general anesthesia or conscious sedation). Documentation should describe the attempts and clinical rationale.

Coding (CDT Codes Provided)

CDT 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 12

1/2

Billing Rule

Local anesthesia billing implications for D9210 and D9215

Local anesthetic administration is considered part of dental procedures and generally is not separately billable. Verify member contract for any plan-specific allowance before billing separate local anesthesia codes.

D9210
D9215

Definitions

General Anesthesia: Drug-induced loss of consciousness where patients are unarousable, may require airway assistance and positive pressure ventilation; cardiovascular function might be impaired.

Deep Sedation/Analgesia: Drug-induced depression of consciousness in which a person is not easily aroused but responds purposefully after repeated or painful stimulation; airway assistance may be required; cardiovascular function is generally preserved.

Intravenous Moderate (Conscious) Sedation/Analgesia: Drug-induced depression of consciousness where the patient remains awake, can follow directions, spontaneous breathing is adequate and no airway interventions are necessary.

Minimal Sedation (Anxiolysis): Drug-induced state allowing normal response to verbal commands with possible cognitive/coordination impairment; airway, breathing and cardiovascular function maintained.

Background: This policy references guidance from professional organizations including the American Dental Association (ADA), American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) regarding the continuum of sedation and monitoring standards.

Application of benefit: The AAP/AAPD define a child as ages 0–21 for clinical guidance, but for benefit determinations the member contract and state-mandated ages for pediatric IV and inhalation anesthesia prevail. Benefit decisions require submission of supporting medical documentation and are subject to the member's contract and state-specific requirements.

Revision History

2024-10-31last_reviewLatest

Periodic annual reviews and minor editorial refinements; intent unchanged.

2025-01-01publish/effective

Policy revision published with effective date; periodic annual review and minor editorial refinements (intent unchanged).