CurrentCignaPolicy 0415

Monitored Anesthesia Care (MAC)/General Anesthesia and Facility Charges for Dental, Oral and Maxillofacial Surgery

Defines when facility and/or monitored anesthesia care (MAC)/general anesthesia and associated facility charges are considered medically necessary or not for dental, oral, and maxillofacial surgery performed in office, outpatient surgery center, or hospital settings under Cigna-administered plans.

Policy Summary

PayerCigna

PolicyMonitored Anesthesia Care (MAC)/General Anesthesia and Facility Charges for Dental, Oral and Maxillofacial Surgery

Policy CodePolicy 0415

Change TypeAnnual review — no clinical policy statement changes

Effective DateAug 15, 2025

Next Review DateAug 15, 2026

Key ActionCheck benefit plan language and prior authorization requirements before billing facility or anesthesia services to ensure criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≤ 7automatic indication for MAC/general anesthesia

ASA ≥ 3ASA qualifying for MAC/general anesthesia

procedural listprocedures where conscious sedation may be inadequate

NMNcosmetic procedures

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covered facility locations when criteria met

annual reviewrevision summary

Coverage Criteria — When Facility and MAC/General Anesthesia Are Medically Necessary

COVERAGE CRITERIA

Covered when ANY of the following locations AND ANY of the following clinical indications are met

Location requirement

Allowed locations (one required): Properly-equipped and staffed office; hospital; outpatient surgery center

Clinical indications (one or more)

Clinical - local anesthesia inappropriate: Local anesthesia not appropriate or indicated due to confirmed toxicity/allergy, medical comorbidity, or acute infection at injection site
Clinical - pediatric age: Individual age seven years or younger<= 7 years
Clinical - cognitive/behavioral impairment: Severely psychologically impaired or developmentally disabled individuals
Clinical - ASA status: ASA Physical Status Classification of 3 or greaterASA >= 3
Clinical - significant comorbidities requiring monitoring: One or more significant medical comorbidities that preclude conscious sedation OR require careful monitoring during and immediately following the planned procedure
Clinical - procedures where conscious sedation inadequate/contraindicated: Includes removal of two or more impacted third molars; removal or surgical exposure of one impacted maxillary canine; surgical removal of two or more teeth involving more than one quadrant; routine removal of six or more teeth; full arch alveoplasty; periodontal flap surgery involving more than one quadrant; radical excision of tooth-related lesion greater than 1.25 cm; tooth-related radical resection or ostectomy with or without grafting; placement or removal of two or more dental implants; tooth transplantation or removal from maxillary sinus; extraction with bulbous root and/or unusual difficulty; removal of exostosis involving two areas; removal of torus mandibularis involving two areas

Medically Necessary Conditions for Facility and Anesthesia Services

Considered medically necessary when used to report facility charges and/or monitored anesthesia care/general anesthesia services for dental procedures performed outpatient, when criteria in the applicable policy statements are met:

Baseline requirements: Facility and anesthesia services must be provided in conjunction with outpatient dental procedures and meet the policy's clinical criteria (patient selection, documentation, safety, trained personnel).

Supported by ASA, AAPD, ADA guidance on personnel, monitoring, and emergency preparedness.

Patient categories warranting anesthesia: Includes pediatric patients unable to cooperate, patients with special health care needs, those requiring significant combined surgical procedures, or where local anesthesia is ineffective or contraindicated.

Per AAPD behavior guidance and management of SHCN.

Higher-risk patients requiring anesthesiology involvement: Patients with ASA III-IV, documented/suspected OSA, morbid obesity (BMI > 40), severe cardiovascular disease, age > 70, chronic liver disease (e.g., MELD >= 10), or other conditions listed by ESA/AAOMS should be evaluated/managed by an anesthesia professional or require consultation/medical clearance.

Anesthesia and associated facility charges billed in conjunction with dental or oral surgery that are performed solely for cosmetic purposes are considered not medically necessary. Claims for anesthesia or facility services for procedures of a cosmetic nature should not be paid under this policy.

The listed professional dental procedure codes (CDT) are provided for reference only and do not imply coverage of the dental procedures themselves; coverage determinations apply to facility and anesthesia services only as described elsewhere in this policy.

Services for cosmetic dental or oral surgery, when anesthesia and/or associated facility charges are billed, are considered not medically necessary and are excluded from coverage under this policy.

Use of general anesthesia is contraindicated for healthy, cooperative patients with minimal dental needs, when requested for convenience of the patient or practitioner, or when predisposing medical conditions make general anesthesia inadvisable.

Coding and Thresholds

Coding information and general instructionmixed

No codes listed

Covered anesthesia and facility CPT/HCPCS codes (when criteria met)CPT|HCPCSCovered

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified.
01999	Unlisted anesthesia procedure(s).
41899	Unlisted procedure, dentoalveolar structures
G0330	Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room

Professional dental procedure CDT codes (reference only)CDT

D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal).
D7230	Removal of impacted tooth - partially bony.
D7240	Removal of impacted tooth - completely bony.
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications.
D7250	Removal of residual tooth roots (cutting procedure).
D7272	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization).
D7310	Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant.
D7311	Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant.
D7320	Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant.
D7321	Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant.

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Age threshold — automatic indication for MAC/general anesthesia for age ≤ 7 years

Age thresholdIndividual age seven years or younger (≤ 7 years)

ContextAutomatic indication for MAC/general anesthesia when local anesthesia is inappropriate or patient is ≤ 7 years

Source noteSee clinical indications listing for pediatric age criteria

ASA threshold — ASA Physical Status Classification of 3 or greater qualifies

ASA thresholdAmerican Society of Anesthesiologists (ASA) Physical Status Classification of 3 or greater (ASA ≥ 3)

Relevance

Provider Actions, Billing, and Documentation Requirements

Denial Risk

Coverage contingent on benefit plan and policy criteria

Coverage for facility and/or monitored anesthesia care (MAC)/general anesthesia services applies only when the applicable policy criteria are met and the member's benefit plan provides coverage for these services. Verify the member's benefit plan document for any plan-specific limitations or state mandates before billing or providing services. Services billed without meeting the criteria or without covered diagnosis/procedure codes will be denied.

Coverage contingent on benefit plan language and state mandates
Claims without covered diagnosis/procedure codes or submitted without meeting policy criteria will be denied

Documentation Required

Document pre-sedation evaluation and facility readiness

Document a comprehensive pre-sedation/preprocedure evaluation and facility readiness prior to performing MAC/general anesthesia. This should include a reviewed medical history, focused physical exam, and any necessary laboratory tests to identify high-risk patients; documentation of airway assessment (e.g., Mallampati score when indicated); and facility emergency preparedness (drugs, equipment, trained staff, and protocol for access to back-up emergency services).

Background

Routine dental procedures for generally healthy patients are typically performed under local anesthesia in office settings. Monitored anesthesia care (MAC) or general anesthesia is reserved for situations when local anesthesia is inappropriate or ineffective (for example due to allergy, toxicity, or infection at the injection site), for pediatric patients age ≤ 7 years, for individuals with severe cognitive or developmental impairment, for patients with higher perioperative risk (e.g., ASA ≥ 3 or other significant comorbidities), or when the planned procedure is such that conscious sedation would be inadequate (see policy for procedural examples). Preprocedure assessment, appropriate monitoring, and facility/equipment readiness are recommended when MAC/general anesthesia is provided.

Definitions and Clinical Terms

Monitored Anesthesia Care (MAC) — definition and components

DefinitionMonitored Anesthesia Care (MAC) is a specific anesthesia service performed by a qualified anesthesia provider that includes preprocedure assessment, intraprocedure care, and postprocedure management, and may include varying levels of sedation up to general anesthesia.

ComponentsIncludes preprocedural assessment and optimization; diagnosis and treatment of intra-procedure problems; support of vital functions including hemodynamic and airway management; administration of sedatives/analgesics; and postoperative medical and pain management.

Provider requirementDuring MAC the anesthesiologist provides or medically directs the bundled services and must be prepared to manage deeper sedation or convert to general/regional anesthetic if needed.

ASA Physical Status Classification — definition and relevance

DefinitionASA Physical Status Classification assesses pre-anesthesia medical comorbidities from ASA I (healthy) to ASA VI (brain-dead organ donor).

Revision History

2025-08-15annual_reviewLatest

Annual review completed; no clinical policy statement changes documented.

2024-08-15annual_review

Annual review completed; no clinical policy statement changes documented.

Policy Summary

PayerCigna

PolicyMonitored Anesthesia Care (MAC)/General Anesthesia and Facility Charges for Dental, Oral and Maxillofacial Surgery

Policy CodePolicy 0415

Change TypeAnnual review — no clinical policy statement changes

Effective DateAug 15, 2025

Next Review DateAug 15, 2026

Key ActionCheck benefit plan language and prior authorization requirements before billing facility or anesthesia services to ensure criteria are met.

SourceLink

On This Page

Per ESA, AAOMS, and other cited guidance.

ASA III or higher listed as a clinical indication for MAC/general anesthesia and associated higher perioperative risk

Clinical actionConsider anesthesia professional involvement and additional monitoring for ASA ≥ 3

Morbid obesity BMI threshold — BMI > 40 kg/m2

Morbid obesity thresholdBody mass index (BMI) > 40 kg/m2

RelevanceMorbid obesity listed among conditions warranting anesthesiology evaluation/management for procedural sedation

Guidance sourceEuropean Society of Anaesthesiology/European Board of Anaesthesiology recommendations

Elderly age threshold — Age > 70 years

Elderly age thresholdAge > 70 years

RelevanceAdvanced age >70 identified as a factor increasing anesthesia risk and indicating anesthesiology professional evaluation

ConsiderationAdvanced age should prompt careful preprocedure assessment and monitoring

Hypotension systolic threshold — SBP < 90 mmHg

Hypotension thresholdSystolic blood pressure (SBP) < 90 mmHg

Clinical implicationModerate to severe hypotension (SBP < 90 mmHg) cited as a condition requiring anesthesiology professional evaluation

Source guidanceEuropean Society of Anaesthesiology/European Board of Anaesthesiology procedural sedation recommendations

Document pre-sedation evaluation, airway assessment (Mallampati if indicated), and any consultations or medical clearances
Ensure and document facility readiness: anesthesia emergency drugs, resuscitation equipment, monitoring devices, and emergency protocols

Documentation Required

Documentation of monitoring and discharge condition

Document intra-procedure monitoring and post-procedure recovery and discharge status. Record continuous monitoring data, the patient's response to anesthesia, and that discharge criteria were met — including return of consciousness/level of responsiveness, stable cardiovascular and airway function, oxygen saturation on room air, ability to sit up or talk if age-appropriate, adequate hydration, and presence of a responsible adult for pediatric transport when applicable.

Document continuous monitoring during sedation and MAC
Document discharge condition: consciousness level, oxygen saturation on room air, airway and cardiovascular stability, and escort arrangements for pediatric patients

Step Therapy

Step therapy — not applicable

Step therapy is not applicable to this policy section; no step therapy requirements are described for facility or MAC/general anesthesia services associated with dental procedures.

No step therapy requirements for anesthesia or facility charges in this policy

Billing Rule

Anesthesia/facility coding and billing restrictions

Facility charges and MAC/general anesthesia services reported with the listed anesthesia and facility codes must meet the policy criteria to be considered medically necessary. Services of a cosmetic nature, or services billed without meeting the listed criteria, are not medically necessary and will be denied.

Only report codes when criteria in the policy are satisfied
Cosmetic dental/oral surgery anesthesia and associated facility charges are not medically necessary

Classification examplesASA I: normal healthy patient; ASA II: mild systemic disease; ASA III: severe systemic disease; ASA IV: severe systemic disease that is a constant threat to life; ASA V: moribund; ASA VI: brain-dead organ donor.

RelevanceHigher ASA status correlates with increased perioperative risk and informs need for anesthesiology involvement

Mallampati score — airway assessment classification definition

DefinitionMallampati score is a visual airway assessment classifying oropharyngeal visibility into Classes I–IV to help predict potential difficulty with intubation.

ClassificationsClass I: entire tonsillar pillars, uvula, hard and soft palates visible; Class II: partial uvula and soft palate visible; Class III: only soft palate visible; Class IV: no structures beyond the tongue visible.

Use limitationUsed with caution in children and not recommended as a stand-alone predictor of a difficult airway

Higher-risk patient — defines higher-risk characteristics (ASA III-IV, OSA, morbid obesity, severe CV disease, advanced age)

Higher-risk patient characteristicsASA physical status III–IV; documented or suspected obstructive sleep apnea (OSA); morbid obesity (BMI > 40 kg/m2); severe cardiovascular disease (including SBP < 90 mmHg); advanced age (> 70 years)

Additional factorsChronic liver disease (MELD ≥ 10), significant comorbidities, anatomical airway abnormalities, or other conditions increasing anesthesia risk requiring anesthesiology professional evaluation/management.

ImplicationThese patients should be evaluated and managed by an anesthesia professional or require consultation/medical clearance prior to procedural sedation/anesthesia.