CurrentCentenePolicy CP.MP.61

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

Defines medical necessity criteria, required documentation, place-of-service appropriateness (in-office vs ASC/hospital outpatient), exclusions/limitations, coding/billing implications, and provider qualifications for IV moderate sedation, IV deep sedation, and general anesthesia for dental procedures for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyIV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

Policy CodePolicy CP.MP.61

Change TypeClarified/administrative updates

Effective Date

Next Review Date

Key ActionSubmit current (<6 months) diagnostic-quality radiographs or intraoral photos and complete chart/treatment documentation (including ASA class, history of failed anesthesia/sedation, treatment plan, social conditions, referring evaluation, and state OP form if applicable) prior to scheduling.

SourceLink

POLICY UPDATE CHANGES

Specified that general criteria in I must be met in addition to POS-specific criteria in II or III and clarified that A (indications), B (lack of contraindications), and C (documentation) must all be met

Replaced 'any' with 'one or more' in I.A with no impact to criteria; combined I.C.1 and I.C.2 previously

1Primary policy reference (CP.MP.61)

D9222,D9223,D9239,D9243,D9248Referenced CDT codes

ASA III/IV <8Not allowed in-office