CurrentCentenePolicy HNCA.CP.MP.61

Dental Anesthesia (PDF)

Medical necessity criteria for intravenous moderate sedation and deep sedation/general anesthesia for dental procedures in inpatient, ambulatory surgery center, community clinic or dental office settings; includes behavioral, clinical and facility requirements and referenced billing codes.

Policy Summary

PayerCentene

PolicyDental Anesthesia (PDF)

Policy CodePolicy HNCA.CP.MP.61

Change TypeRevised (code and APL alignments)

Effective Date

Next Review Date

Key ActionProvider must document that local anesthesia failed or was not feasible and that minimal sedation (inhalation or oral) failed or was not feasible based on the member's medical needs.

SourceLink

POLICY UPDATE CHANGES

Policy updated over time to comply with CA DHCS APLs and combined Centene policy with APL guidelines; CPT code 41899 added.

4Qualifying indication categories (behavior/immobilization/extensive treatment/anxiety/uncooperative)

8Representative referenced CPT/CDT codes

1Referenced clinical policy number

Coverage Summary

This policy (HNCA.CP.MP.61, status CURRENT) covers intravenous moderate sedation and deep sedation/general anesthesia for dental procedures as medically necessary when specified criteria are met. It applies to services provided in inpatient settings, ambulatory surgery centers (ASC), applicable community clinics, or dental offices and requires documentation of the clinical indications and adherence to the policy criteria.

Medically Necessary Criteria for IV Moderate Sedation and Deep Sedation/General Anesthesia

Requests are considered medically necessary when ALL of the following are met:

ALL of the following

Behavior modification and local anesthesia must generally be attempted first, but may not be required in certain situations, depending on the medical needs of the member.
Minimal sedation must be considered or determined not feasible based on the medical needs of the member; minimal sedation is not always required depending on medical needs.
Documentation requirements (both required)
- Use of local anesthesia to control pain failed or was not feasible based on the medical needs of the member.
- Use of minimal sedation, either inhalation or oral, failed or was not feasible based on the medical needs of the member.
If ANY one of the following is documented, member must be considered for IV moderate sedation or deep sedation/general anesthesia
- Use of effective communicative techniques and the inability for immobilization (member may be dangerous to self or staff) failed or was not feasible based on the medical needs of the member.
- Member requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or minimal sedation.
- Member has acute situational anxiety due to immature cognitive functioning.
- Member is uncooperative due to certain physical or mental compromising conditions.
Members with certain medical conditions (e.g., moderate to severe asthma, reactive airway disease, congestive heart failure, cardiac arrhythmias, significant bleeding disorders, uncontrolled seizures, sleep disordered breathing) should be treated in a hospital setting or licensed facility capable of responding to a serious medical crisis as determined by the provider.
Providers must adhere to all regulatory requirements for preoperative/perioperative care, monitoring and equipment requirements, emergencies and transfers, and monitoring guidelines; all locations administering general anesthesia must be equipped with emergency drugs, resuscitation equipment and trained staff.

Provider Actions & Documentation Requirements

Documentation Required

Document failure or infeasibility of local anesthesia and minimal sedation

Document in the medical record that local anesthesia failed or was not feasible and that minimal sedation (inhalation or oral) failed or was not feasible based on the member's medical needs.

Documentation Required

Document one qualifying indication

Document at least one qualifying indication for IV moderate sedation or deep sedation/general anesthesia.

Failure of immobilization or inability to safely immobilize (may be dangerous to self or staff)
Extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or minimal sedation
Acute situational anxiety due to immature cognitive functioning
Uncooperative due to physical or mental compromising conditions

Documentation Required

Treat members with specified comorbidities in appropriate facility

Treat members who have the listed medical comorbidities in a hospital setting or licensed facility capable of responding to a serious medical crisis, as determined by the provider.

Moderate to severe asthma
Reactive airway disease
Congestive heart failure
Cardiac arrhythmias
Significant bleeding disorders
Uncontrolled seizures
Sleep disordered breathing

Documentation Required

Adhere to regulatory and monitoring requirements

Ensure providers and locations administering general anesthesia meet applicable federal, state and licensing requirements for preoperative/perioperative care, monitoring and equipment, have anesthesia emergency drugs and resuscitation equipment available, and maintain trained staff and transfer procedures for emergencies.

Referenced Codes

CPT referenced (informational)CPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified.
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified.
41899	Unlisted procedure, dentoalveolar structures (facility fees).

Dental anesthesia CDT/D codesmixed

D9222	Deep sedation/general anesthesia, first 15 minutes.
D9223	Deep sedation/general anesthesia, each subsequent 15 minutes.
D9239	Intravenous moderate (conscious) sedation/analgesia, first 15 minutes.
D9243	Intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minutes.

Background and Guideline Context

This clinical policy defines selection criteria for IV moderate sedation and deep sedation/general anesthesia based on the member’s medical history, physical status, and documented indications for anesthetic management. It ranks procedures from minimal sedation (inhalation or oral) through non-intravenous conscious sedation, IV moderate sedation, then deep sedation/general anesthesia and specifies that dental and anesthesia providers collaborate to determine appropriateness.

The policy emphasizes that behavior modification and local anesthesia should generally be attempted first and that minimal sedation must be considered or documented as not feasible before progressing to IV moderate or deep/general anesthesia. It requires documentation that local anesthesia and minimal sedation failed or were not feasible and that at least one qualifying indication (e.g., failure of immobilization, need for extensive treatment not possible under local/minimal sedation, acute situational anxiety from immature cognition, or uncooperative due to physical/mental conditions) is present. Providers and locations administering general anesthesia must meet regulatory and monitoring requirements and be equipped with emergency drugs, resuscitation equipment, and trained staff; members with significant comorbidities (e.g., moderate–severe asthma, reactive airway disease, CHF, arrhythmias, bleeding disorders, uncontrolled seizures, sleep disordered breathing) should be treated in a hospital or licensed facility capable of responding to serious medical crises. The policy aligns with state DHCS All Plan Letters and professional society guidelines and includes referenced coding and administrative updates.

Revision History

05/15revised

Extensive revisions to comply with CA DHCS APL 15-012; policy updated.

06/15revised

Extensive revisions to comply with CA DHCS APL 15-012; approval recorded.

06/16revised

Extensive revisions to combine Centene clinical policy with CA DHCS APL 15-012; policy updated and approved.

05/17revised

Changed policy to new template; updated Policy/Criteria based on DHCS and Denti-Cal materials; added CPT code 41899 and attachments from APL/DHCS presentation.

08/17revised

Removed an already approved TAR as one of the criteria for approval based on DHCS/Denti-Cal guidance; references reviewed and updated.

04/19revised

Combined corporate policy with APL guidelines and approved it for all product lines.

04/20revised

References reviewed and updated; code updates applied.

04/21revised

Reviewed - no changes.

04/22revised

Reviewed - no changes; codes updated.

11/22revised

No changes.

11/23revised

Added reference to APL 23-028 for Medi-Cal.

12/23revised

Revised to reflect APL-23-028 requirements.

02/24-02/26revisedLatest

No changes (policy reviewed with no changes through 02/26).

Policy Summary

PayerCentene

PolicyDental Anesthesia (PDF)

Policy CodePolicy HNCA.CP.MP.61

Change TypeRevised (code and APL alignments)

Effective Date

Next Review Date

Key ActionProvider must document that local anesthesia failed or was not feasible and that minimal sedation (inhalation or oral) failed or was not feasible based on the member's medical needs.

SourceLink

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