CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

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Defines medical necessity, monitoring, documentation, and coverage positioning for local, regional, inhalation, conscious sedation, and general anesthesia in dental settings; applies when anesthesia is provided in conjunction with covered dental or medical benefits or when state mandates require coverage.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeAnnual review

Effective DateJan 1, 2021

Last ReviewDec 6, 2020

Next Review Date

Key ActionSubmit supporting medical documentation from oral surgeon, dentist and/or physician when medical conditions necessitate general anesthesia; include evidence that local anesthesia would be ineffective

SourceLink

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CurrentBlue Cross Blue Shield - WisconsinPolicy 09-201

Inhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyInhalation and Local Anesthesia (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 09-201

Change TypeAnnual review

Effective DateJan 1, 2021

Last ReviewDec 6, 2020

Next Review Date

SourceLink

Coverage Summary

This policy defines medical necessity, monitoring, documentation, and coverage positioning for local, regional, inhalation, conscious sedation, and general anesthesia in dental settings. Coverage is conditional and generally available only when anesthesia is provided in connection with underlying services that are covered under the dental or medical benefits plan or when required by a state mandate, and depends on meeting the policy's medical necessity criteria and applicable contract or state requirements.

Policy summary

Effective date01/01/2021

Last review12/06/2020

Policy statusCURRENT

Policy number09-201

Office anesthesia duration documentation threshold> 60 minutes requires written rationale/documentation

Medical-Necessity Criteria

General medical necessity definition

Covered when ALL of the following are met:

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 function consistent with prevailing community standards for the diagnosis or condition
In accordance with generally accepted standards of dental practice (based on peer-reviewed evidence, specialty society recommendations, and views of recognized dentists)

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Coding

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

1/2

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

1/2

Provider Actions

Prior Authorization

Potential utilization review

Anesthesia services may be subject to utilization review for medical or dental necessity. Verify the member's dental and medical benefit plans for any preauthorization or plan-specific requirements before providing advanced anesthesia services.

Documentation Required

Medical documentation for advanced anesthesia

Submit supporting documentation from the oral surgeon, dentist and/or physician when medical conditions necessitate general anesthesia or conscious sedation. Documentation should verify the member's medical condition(s) and support that local anesthesia would be ineffective or inappropriate for successful treatment.

Documentation Required

Anesthesia record maintenance

Background and Evidence

The policy references guidance from 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 requires that dentists administering anesthesia be appropriately educated, trained and licensed, that monitoring (including oxygenation, pulse oximetry, ventilation, respirations, blood pressure and heart rate) be continuous and documented, and that a complete anesthesia record (drug names, times, dosages and physiologic parameters) be maintained. Coverage for anesthesia depends on its connection to covered dental services or applicable state mandates.

Guideline references: ADA, AAP/AAPD, ASA, AAOMS documents cited (see references list).

Definitions

Medically/Dentally Necessary (definition)Services consistent with the member's diagnosis/condition, rendered for life‑threatening condition or pain, to treat dentition‑related injury/illness/infection, or to achieve dentition function consistent with community standards

Child (clinical reference)AAP/AAPD define child as ages 0 to 21; for benefit purposes Anthem follows contract and state‑mandated ages

Revision History

2020-11-12annual_review

Policy revised with annual review noted on 11/12/2020 (committee review); revision recorded as Annual Review in revision history.

2020-12-06annual_reviewLatest

Policy revised with annual review noted on 12/06/2020 (committee review); listed as Last Review Date 12/06/2020 and Publish Date 01/01/2021.

Eligibility for advanced anesthesia (general anesthesia / conscious sedation)

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

ONE of

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)
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); must be verified by appropriate medical documentation
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs that should not be postponed and for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral morbidity
Local anesthesia is ineffective for the member (e.g., acute infection, anatomic variations, allergy); failed attempts of local anesthesia administration must be documented and submitted for review
Member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised

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Monitoring, documentation and facility/provider requirements

Applicable requirements that must be met for anesthesia services:

ALL of the following

Dentist or appropriately trained individual must remain in the operatory during active dental treatment to continuously monitor vital signs until patient meets discharge criteria
Monitoring must include observation of proper oxygenation (including mucosal color) and oxygen saturation by pulse oximetry
Ventilation: chest movement must be continually observed; respirations must be verified and documented by appropriately trained personnel
Circulation: blood pressure and heart rate must be evaluated pre-operatively, intra-operatively and post-operatively and properly documented
An appropriate, complete anesthesia record must be maintained including names of all drugs administered, times, dosages, and all physiological parameters
When more advanced anesthetics (IV or inhalation) are used to induce more profound levels of anesthesia, additional individuals trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist/oral surgeon
If required by state, current equipment inspection certificate, sedation license and CPR certification are mandatory
Dentist administering the anesthesia must remain in constant attendance with the patient until completion of the anesthesia procedure
Time of general anesthesia begins when the dentist starts administering the sedative agent and non-invasive monitoring protocol
Services are considered complete when the patient may be safely left under observation of trained personnel and the dentist may safely leave the operatory
Office anesthesia in excess of 60 minutes for any dental or surgical procedure requires written rationale/documentation explaining the necessity> 60 minutes requires written rationale/documentation
Medical conditions requiring general anesthesia must be supported by documentation from the oral surgeon, dentist and/or physician administering the anesthesia
Medical documentation must support conditions that preclude successful treatment under local anesthesia

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