CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

Inhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

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 inhalation nitrous oxide in dental settings for Blue Cross Blue Shield - Wisconsin; applies when anesthesia is provided in conjunction with covered dental services or as required by state mandate.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeRevised

Effective DateJan 1, 2024

Next Review Date

Key ActionFor members meeting criteria due to medical/behavioral conditions, submit medical documentation from physician/oral surgeon/dentist to support necessity.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised with last review date 11/01/2023 and publish date 01/01/2024.

12CDT Codes Listed

1Policy Guideline Number

>60 minAnesthesia duration threshold requiring documentation

Coverage Summary

Medical-Necessity Criteria

General Medical Necessity

Anesthesia services are covered only when medically/dentally necessary in connection with covered dental services or where mandated by state law. Covered when ALL of the following are met:

ALL of the following

Service is consistent with the member's diagnosis or condition
Service is rendered in response to life‑threatening condition or pain, or to treat injury/illness/infection related to the dentition, or to achieve dental function consistent with community standards
Service is in connection with underlying dental services that are covered under the dental or medical benefits plan or qualifies via state mandate

Deep Sedation/General Anesthesia and Conscious Sedation Benefit Criteria

To qualify for general anesthesia or conscious sedation benefit, the member must satisfy 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 such 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 (conditions include but not limited to intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, hyperactivity) and supported by medical documentation
Medical documentation from physician/oral surgeon/dentist required
The member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs which should not be postponed and for whom lack of treatment would likely result in oral pain, infection, tooth loss, or increased oral morbidity
Local anesthesia is ineffective for the member (e.g., due to acute infection, anatomic variations, allergy); failed attempts must be documented and submitted for review
Document failed attempts at local anesthesia

Inhalation Nitrous Oxide/Analgesia

Nitrous oxide may be covered when used in conjunction with covered dental services and when clinically indicated; covered when ANY of the following indications are present:

ANY of the following

Ineffective local anesthesia administration
Treatment of dental anxiety
Special needs patients
Individuals who are uncooperative or behaviorally challenged

Contraindications (not covered/contraindicated)

Patients with severe respiratory compromise

Local Anesthesia

Local anesthesia is considered inclusive of dental procedures and is not separately benefitable except where a specific plan allows separate coverage.

Administration of local anesthetic (traditional, electronic, buffered, etc.) is considered inclusive to all dental procedures and is not eligible for separate benefit unless a specific plan allows coverage

Regional and Trigeminal Division Block Anesthesia

Coverage stance:

Regional and trigeminal block anesthesia may not be a covered service

Provider Actions

Documentation Required

Medical documentation for general anesthesia/conscious sedation

For members meeting criteria due to medical or behavioral conditions, medical documentation from the physician, oral surgeon, or dentist must be submitted to support the medical necessity of general anesthesia or conscious sedation.

Documentation Required

Anesthesia record and monitoring documentation

Maintain a complete anesthesia record including the names of all drugs administered, times of administration and dosages, and physiologic monitoring. Continuous monitoring must include observation of oxygenation (including mucosal color), pulse oximetry, ventilation (chest movement and respirations), and circulation (blood pressure and heart rate) with documentation pre-, intra- and post-operatively; required for review and excess time justification.

Documentation Required

Documentation for failed local anesthesia

Document failed attempts at local anesthesia and the reasons (for example acute infection, anatomic variation, or allergy) and submit that documentation for review when claiming general anesthesia because local anesthesia was ineffective.

Billing Rule

Local anesthesia not separately billable

Local anesthetic administration is considered inclusive to all dental procedures and is not eligible for a separate benefit unless a specific plan allows separate coverage.

D9210
D9215

Prior Authorization

Prior review may be required

Verify the member's contract benefits or contact customer service to determine whether prior review or authorization is required for anesthesia services under the applicable plan.

Documentation Required

Documentation for anesthesia >60 minutes

For office anesthesia exceeding 60 minutes, provide a written rationale and complete supporting documentation, including all associated x-ray images, progress notes, operative report and a complete anesthesia record indicating start and stop times of incremental drug administration.

Denial Risk

Coverage contingent on underlying service coverage

Anesthesia benefits are available only in connection with underlying dental or medical services that are covered under the member's plan or when required by state mandate; claims may be denied if the underlying services are not covered or there is no applicable state mandate.

Background

The policy references guidance from major specialty organizations including the American Dental Association (ADA), American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Society of Anesthesiologists (ASA), and the American Association of Oral and Maxillofacial Surgeons (AAOMS). It emphasizes adherence to these guidelines and recognized standards of care for dental anesthesia.

Policy emphasis is on safety, including appropriate education, training and licensure of providers; monitoring (continuous vital sign observation, pulse oximetry, ventilation and circulation checks); documentation (complete anesthesia record with drugs, times, dosages and physiologic parameters); and required emergency management/equipment. The policy also stresses that anesthesia benefits must be linked to covered dental services or state mandates and that additional personnel and certifications may be required when IV or inhalation agents are used.

Definitions

TermMedically/Dentally Necessary

DefinitionServices consistent with the Member's diagnosis or condition and rendered in response to life‑threatening condition/pain, to treat injury/illness/infection related to dentition, or to achieve dental function consistent with community standards.

Revision History

2014-01-01Version

Initial version published 01/01/2014.

2017-02-08Revision

Revision recorded on 02/08/2017.

2018-02-06Revision

Revision addressing appropriateness and medical necessity on 02/06/2018.

2020-11-12Revision

Annual Review revision recorded on 11/12/2020.

2020-12-06Revision

Annual Review revision recorded on 12/06/2020.

2021-10-20Revision

Annual Review revision recorded on 10/20/2021.

2022-11-11Revision

Annual Review revision recorded on 11/11/2022.

2023-11-01Annual ReviewLatest

Policy status marked Revised with last review date 11/01/2023 and publish date 01/01/2024.

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

OpenPayer

Inhalation and Local Anesthesia (2024 Policy) PDF. Opens in a new window

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background

Revision History