CurrentBlue Cross Blue Shield - WisconsinPolicy 09-600

Therapeutic Parenteral Drug Administration (Dental)

Guidance governing when therapeutic parenteral (IV/IM/SC/intradermal) drug administration in dental settings is reviewed for medical/dental necessity and benefit determination under the payer's dental plans; affects dental providers seeking coverage for parenteral therapeutic medications.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyTherapeutic Parenteral Drug Administration (Dental)

Policy CodePolicy 09-600

Change TypeNo material changes

Effective Date01/01/2023

Next Review Date

Key ActionSubmit CDT procedure codes D9610, D9612, or D9613 as applicable for benefit consideration and include clinical chart notes with medication name and dosage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CDT codes listed

4Clinical criteria bullets

2023-01-01Publish date

Coverage Criteria

Medically Necessary / Benefitted Parenteral Administration

Covered when ALL of the following are met:

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Core coverage conditions: Parenteral administration is performed via intravenous, intramuscular, subcutaneous or intradermal routes AND the medication is a therapeutic agent (e.g., antibiotics, steroids, anti-inflammatories or other therapeutic medications) intended to improve surgical healing, reduce pain and/or treat infection AND the service meets generally accepted standards of dental practice (type, frequency and extent appropriate and not primarily for patient or dentist convenience).

Does not include sedative, anesthetic or reversal agents; does not include infiltration of sustained-release pharmacologic agent for long-acting surgical site pain control.

Documentation and submission requirements: Clinical chart notes and narrative may be requested to explain the rationale for the medication; the name and dosage of the medication administered must be submitted for benefit consideration.

Exclusions and limitations: Procedures that are experimental, investigational or unproven are not benefitted; drug administration for cosmetic purposes is not a benefitted service.

Provider Actions & Billing Guidance

Billing Rule

Coding required for benefit consideration

Submission of CDT procedure codes D9610, D9612, or D9613 (as applicable) is used for benefit consideration of therapeutic parenteral drug administration. Inclusion of a code here does not guarantee coverage; verify member contract benefits at time of service.

D9610 — Therapeutic parenteral drug, single administration
D9612 — Therapeutic parenteral drugs, two or more administrations, different medications
D9613 — Infiltration of sustained release therapeutic drug - single or multiple sites

Step Therapy

Step therapy

No step therapy requirements specified in this document.

Documentation Required

Required documentation

Clinical chart notes and narrative may be requested to explain the rationale for the medication. The name and dosage of the medication administered must be submitted for benefit consideration.

Provide clinical chart notes and narrative explaining rationale
Include medication name and dosage

Denial Risk

Experimental/Unproven procedures

Procedures that are considered experimental, investigational or unproven are not benefitted.

Denial Risk

Cosmetic use excluded

Drug administration for cosmetic purposes is not a benefitted service.

Background

Therapeutic parenteral drug administration in dental care includes intravenous (IV), intramuscular (IM), subcutaneous (SC) or intradermal routes for delivery of therapeutic agents such as antibiotics, steroids, anti‑inflammatory or other medications intended to improve surgical healing, reduce pain and/or treat infection. Clinical documentation (chart notes and narrative) may be requested to explain the medication rationale, and the name and dosage of the medication administered must be submitted for benefit consideration.

Definitions

Parenteral administration — Definition

DefinitionParenteral administration of drugs is any technique in which the route of administration is intravenous, intramuscular, subcutaneous or intradermal.

Excluded usesUse of parenteral administration to report sedative, anesthetic or reversal agents is not benefitted.

Cosmetic useDrug administration for cosmetics is not a benefitted service.

Documentation requiredClinical chart notes and narrative may be requested to explain the rationale for the medication; the name and dosage of the medication administered must be submitted for benefit consideration.