CurrentCentenePolicy CPMP.61

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures

Governs medical necessity, required documentation, place-of-service selection, and coding for intravenous moderate sedation, IV deep sedation, and general anesthesia for dental procedures for members of Centene-affiliated health plans.

Policy Summary

PayerCentene

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

Policy CodePolicy CPMP.61

Change TypeMinor wording updates / references updated

Effective Date

Next Review Date

Key ActionDocument failed attempts at less invasive behavior or analgesia management and include required pre-operative documentation when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age < 8special pediatric considerations and higher-risk group

≥ 7threshold for extensive pediatric treatment indicating ASC/hospital venue

2+ impactedexample of complex surgical procedure covered

ASA III/IVASA classification that may preclude in-office setting for <8 years

>4 units

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More than four units requires sedation log

D9222-D9248Dental anesthesia CDT codes referenced

Coverage Criteria

General medical necessity and place-of-service-specific criteria

Covered when ALL of the following general criteria and applicable place-of-service-specific criteria are met:

General requirements (I): All of the following must be satisfied: A. One or more documented indications (e.g., extreme anxiety with failed local/inhaled/oral sedation attempts; underlying medical conditions documented in records; documented physical, cognitive, or developmental disability causing non-compliance; allergy or sensitivity to local anesthesia; pediatric resistance to behavior management; lengthy and numerous (>4) restorative procedures for pediatric patients; history of uncooperative behavior posing safety risk; documented relevant social impact conditions; complex/extensive surgical procedures such as >=2 impacted teeth in >=2 quadrants or >=2 extractions of permanent teeth per quadrant in at least two quadrants). B. None of the contraindicating conditions (e.g., predisposing medical/physical conditions that would make general anesthesia unsafe). C. Required documentation is present (current <6 months diagnostic-quality pre-op radiographs or intraoral photos when radiographs not achievable; patient chart and treatment notes supporting medical necessity and ICD-10 diagnoses; documentation of non-clinical/social conditions; complete treatment plan; specific history of failed anesthesia/sedation/analgesia attempts; ASA classification with note that ASA III/IV for patients under age 8 will not be approved for a dental office setting; referring dentist evaluation records; state-mandated outpatient form if applicable).

References: policy section I and documentation requirements

Place of service - In-office (II): In-office IV sedation or general anesthesia is appropriate when the general criteria (I) are met, the member has no significant medical comorbidities, and one or more of the following apply: pediatric limited treatment need (4–6 teeth requiring restoration/pulpotomy/extraction); moderate or situational anxiety; pediatric social impact conditions necessitating single-visit completion; pediatric <8 years with medically necessary services and uncompromised airway; pediatric <8 years meeting ASA I or II; extraction of >=2 impacted teeth in >=2 quadrants; extraction of >=2 permanent teeth per quadrant involving two or more quadrants.

Refer to in-office criteria in section II

Place of service - ASC/Hospital (III): ASC or hospital outpatient venue is appropriate when the general criteria (I) are met and any of the following apply: local factors/access/state regulations permit ASC; member has compromising medical comorbidities; pediatric extensive treatment needs (>=7 primary teeth requiring restoration/pulpotomy/extraction); pediatric social impact conditions when in-office anesthesia is not accessible; pediatric combination of >=4 primary teeth and at least one major medical comorbidity; pediatric <8 years with compromised/obstructed airway or ASA III/IV; extraction of >=2 impacted teeth in >=2 quadrants in combination with a major medical comorbidity; extraction of >=2 permanent teeth per quadrant in >=2 quadrants in combination with a major medical comorbidity.

Refer to ASC/hospital criteria in section III

General requirement

General policy structure notes

General and place-of-service relationship: General criteria in section I (indications, absence of contraindications, and required documentation) must be met in addition to the applicable place-of-service specific criteria in section II (in-office) or section III (ASC/hospital). Approval requires that indications, lack of contraindications, and documentation are all satisfied.

Policy clarifies that I plus II or III are required; see revision history for editorial changes.

The policy explicitly lists as an exclusion members with predisposing medical or physical conditions that would make general anesthesia unsafe. Documentation should demonstrate the medical contraindication and support selection of an alternate venue (e.g., ASC or hospital) when anesthesia would be unsafe in an office setting.

The revision history documents that HCPCS code D9230 was removed from the policy and is no longer referenced in coding or coverage sections.

The policy identifies circumstances in which general anesthesia or IV moderate/deep sedation is not medically necessary: when the member is cooperative with minimal dental needs, has a history of tolerating similar procedures without sedation, or when sedation/general anesthesia is requested solely for patient or provider convenience. These conditions, when present and documented, increase the likelihood of denial absent other supporting indications for anesthesia.

Coverage determinations are based on the presence of required documentation and applicable indications rather than blanket statements alone. The policy requires current (<6 months) diagnostic-quality pre‑operative radiographs or intraoral photos as applicable, patient chart and treatment notes documenting medical necessity and ICD‑10 diagnoses, history of failed anesthesia/sedation attempts, ASA classification, and other supporting records; these documentation requirements guide approval decisions and are listed in the policy’s required supporting documentation section.

Coding and Billing

Referenced CDT CodesCDT

D9222	Deep sedation/general anesthesia first 15 minutes
D9223	Deep sedation/general anesthesia each subsequent 15-minute increment
D9239	Intravenous moderate conscious sedation/analgesia first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation

Referenced CPT Anesthesia CodesCPT

00170	Anesthesia for intraoral procedures, including biopsy, not otherwise specified
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified

Covered CDT Codes (as referenced)mixed

D9222	Deep sedation/general anesthesia first 15 minutes
D9223	Deep sedation/general anesthesia each subsequent 15-minute increment
D9239	Intravenous moderate conscious sedation/analgesia first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation

Referenced CPT CodesCPT

00170	Anesthesia for intraoral procedures, including biopsy, not otherwise specified
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified

D9223/D9243 units — Sedation log requirement

ThresholdMore than four units of D9223 or D9243 billed on a single date of service requires submission of a copy of the sedation log (subject to state-specific regulations).

Related billing limitOnly one D9222 or D9239 is allowed per date of service; multiple first-unit codes may trigger denial.

Documentation consequenceBilling in excess of the threshold without the required sedation log may result in claim denial.

Units threshold for D9223/D9243

Units thresholdMore than four units of D9223 or D9243 per date of service requires a copy of the sedation documentation (sedation log), subject to state-specific regulations.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization and Coding References

Prior authorization is required. Intravenous moderate/deep sedation and general anesthesia require documentation of medical necessity and determination of appropriate place of service. Ensure claims and prior auth requests include the clinical criteria that justify sedation or anesthesia and follow coding limits.

Prior authorization required for IV moderate/deep sedation and general anesthesia
Documentation must demonstrate place-of-service determination (in-office vs ASC/hospital)

Billing Rule

Prior Authorization / Coding — Coverage and Limits

Coverage and coding limitations: adhere to CDT/HCPCS and CPT anesthesia code guidance and the policy's coding restrictions. Billing must follow the policy limits and required supporting documentation to avoid denials.

Background

Intravenous moderate sedation, IV deep sedation, and general anesthesia may be necessary to safely provide dental care in office, ambulatory surgery center, or hospital settings. The policy notes that pediatric patients have higher risk and that deep sedation or general anesthesia in office may be appropriate for selected pediatric patients only in properly equipped and staffed facilities, and that providers should follow applicable professional society guidance (ADA, AAP, AAPD, ASA).

Definitions

IV Moderate Sedation — definition and key features

DefinitionIV Moderate Sedation: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, may respond to light tactile stimulation, airway and spontaneous ventilation are maintained, and cardiovascular function is usually maintained.

Airway/ventilationNo interventions required to maintain a patent airway; spontaneous ventilation is adequate.

Response levelPatients remain responsive to verbal commands (purposeful responses distinguish moderate sedation from deeper states).

IV Deep Sedation — definition and key features

DefinitionIV Deep Sedation: A drug-induced depression of consciousness in which patients cannot be easily aroused but may respond purposefully after repeated verbal or painful stimulation; airway maintenance may be impaired and spontaneous ventilation may be inadequate; cardiovascular function is usually maintained.

Policy Summary

PayerCentene

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

Policy CodePolicy CPMP.61

Change TypeMinor wording updates / references updated

Effective Date

Next Review Date

Key ActionDocument failed attempts at less invasive behavior or analgesia management and include required pre-operative documentation when requesting authorization.

SourceLink

On This Page

Per-date ruleThreshold applies per single date of service, not per procedure or encounter.

Denial riskFailure to provide the required documentation for >4 units may trigger denial of the claim.

Follow CDT codes D9222, D9223, D9239, D9243, D9248 and applicable CPT/HCPCS anesthesia codes
Billing must comply with per-date-of-service code limits and documentation requirements

Denial Risk

Denial Risk Conditions

Requests may be denied when clinical criteria do not support medical necessity. Avoid requests where the member is cooperative with minimal dental needs, has tolerated similar procedures without sedation, or when anesthesia is requested for convenience.

Denial risk when member/enrollee is cooperative and has minimal dental needs
Denial risk when member/enrollee has history of tolerating similar dental procedures without sedation
Denial risk for requests made for patient or provider convenience

Billing Rule

Duplicate First‑Unit Codes

Do not bill duplicate first-unit codes on the same date of service. Only one first-unit code is allowed per date of service for the respective sedation/anesthesia category.

Only one D9222 (deep sedation/general anesthesia first 15 minutes) allowed per date of service
Only one D9239 (IV moderate conscious sedation first 15 minutes) allowed per date of service

Documentation Required

Required Supporting Documentation

Provide required supporting documentation with prior authorization and claims. Include recent diagnostic imaging and complete clinical records that substantiate medical necessity.

Current (<6 months) diagnostic-quality pre-operative radiographs when achievable, or intraoral photos if radiographs are not achievable
Complete patient chart and treatment notes documenting dental and medical diagnoses and ICD-10 codes
Complete treatment plan and referring dentist evaluation records
ASA physical status classification and state-mandated outpatient form, if applicable

Documentation Required

Documentation Required for >4 Units

When billing more than four units of subsequent-unit codes, include additional sedation documentation per state regulations. Lack of required documentation for excess units may trigger claim denial.

More than four units of D9223 or D9243 per date of service requires submission of a copy of the sedation record (subject to state-specific regulations)
Billing >4 units without the required sedation record may be denied

Documentation Required

Conservative Therapy Attempts Required

Conservative therapy attempts must be documented prior to approval for sedation/anesthesia. Record failed attempts at less invasive behavior or analgesia management.

Documented failed attempts at local anesthesia, nitrous oxide inhalation, or oral conscious sedation/analgesia
Documentation of attempts at conventional behavior management for pediatric members (e.g., tell-show-do) and failed results

Step Therapy

No step therapy requirements are specified for sedation or anesthesia in this section of the policy.

There are no step therapy rules applicable to IV moderate/deep sedation or general anesthesia in this portion of the policy

Airway/ventilationPatients may require assistance in maintaining a patent airway; spontaneous ventilation may be inadequate.

Response levelPurposeful responses only after repeated stimulation; reflex withdrawal alone is not considered purposeful and suggests general anesthesia.

General Anesthesia — definition and key features

DefinitionGeneral Anesthesia: A drug-induced loss of consciousness during which patients are not arousable even by painful stimulation; ability to independently maintain respiratory function is often impaired and positive-pressure ventilation may be required; cardiovascular function may be impaired.

Airway/ventilationPatients often require assistance to maintain a patent airway and may need positive-pressure ventilation due to depressed spontaneous ventilation or neuromuscular blockade.

Level of consciousnessPatients are not arousable, distinguishing general anesthesia from deep sedation and moderate sedation.

Sedation/Anesthesia CDT codes — first 15-minute and subsequent units

D9222Deep sedation/general anesthesia — first 15 minutes (CDT).

D9223Deep sedation/general anesthesia — each subsequent 15-minute increment (CDT).

D9239Intravenous moderate conscious sedation/analgesia — first 15 minutes (CDT).

D9243Intravenous moderate (conscious) sedation/analgesia — each subsequent 15-minute increment (CDT).

D9248Non-intravenous conscious sedation (CDT).