Colorado Rocky Mountain — Anesthesia Policy Update

Coverage Summary

Policy DCP016.18 provides coverage criteria for general anesthesia and conscious sedation services in dental office settings. It defines indications, contraindications, definitions, and applicable CDT procedure codes for nitrous oxide, non-intravenous sedation, intravenous moderate/deep sedation, and general anesthesia. This policy applies specifically to services provided in a dental office; for services provided in a hospital operating room or ambulatory surgery center, the member-specific benefit plan and applicable federal or state mandates should be referenced.

Status: CURRENT. Effective date and last review: 2026-01-01.

Nitrous Oxide — Indications & Contraindications

Indications for Nitrous Oxide

Nitrous Oxide may be indicated for the following:

ALL of the following

Extensive and/or complex procedures (e.g., serial extractions, periodontal surgeries)
Individuals with physical, cognitive, or developmental disabilities
Ineffective Local Anesthesia
Management of a severe gag reflex
Management of fear and anxiety

Top-level 'all' operator grouping for nitrous oxide indications

Contraindications for Nitrous Oxide

Nitrous Oxide may be contraindicated for the following (this list is not all-inclusive):

ANY of the following

Claustrophobia
Pregnancy
Severe underlying medical conditions (e.g., critical illnesses, cardiac disease, pulmonary hypertension)
Significant personality and behavioral disorders
Upper respiratory tract infections or other respiratory conditions

Absolute contraindications

Intravenous Moderate/Deep Sedation & General Anesthesia — Indications

Indications for Intravenous Moderate/Conscious Sedation and Deep Sedation/General Anesthesia

Intravenous Moderate/Conscious Sedation and Deep Sedation/General Anesthesia may be indicated for the following:

ALL of the following

Allergy or sensitivity to local anesthetic agents
Extensive and/or complex procedures (e.g., serial extractions, periodontal surgeries)
Anxiety and fear when other techniques have proven inadequate
Behavioral management when other techniques have proven inadequate

Non‑Intravenous Sedation — Indications

Indications for Non-Intravenous Sedation

Non-Intravenous Sedation may be indicated for the following situations:

ALL of the following

Individuals with physical, cognitive, or developmental disabilities
Mild to moderate apprehension and anxiety

Top-level 'all' operator grouping for non-intravenous sedation indications

General Contraindications for All Types of Sedation and General Anesthesia

All types of sedation and General Anesthesia may be contraindicated if there is an increased risk of adverse outcomes or complications. These include but are not limited to:

ANY of the following

Abnormalities of the major organ systems
Previous adverse experience with sedation/analgesia
Drug allergies
Current medications and potential drug interactions

Applicable CDT Procedure Codes (reference)

Applicable CDT procedure codes (reference only)mixed

D9210	Local anesthesia not in conjunction with operative or surgical procedures.
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia.
D9215	Local anesthesia in conjunction with operative or surgical procedures.
D9219	Evaluation for moderate sedation, deep sedation or general anesthesia.
D9222	Administration of deep sedation/general anesthesia - first 15 minute increment, or any portion thereof.
D9223	Administration of deep sedation/general anesthesia - each subsequent 15 minute increment, or any portion thereof.
D9224	Administration of general anesthesia with advanced airway - first 15 minute increment, or any portion thereof.
D9225	Administration of general anesthesia with advanced airway - each subsequent 15 minute increment, or any portion thereof.
D9230	Administration of nitrous oxide.

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The listed CDT anesthesia and sedation codes (D92xx series) are provided for reference only and do not guarantee coverage or reimbursement. Report applicable CDT codes as appropriate but verify benefit coverage with the member-specific plan.

See provider action: Use listed CDT codes for anesthesia/sedation services, which reiterates that the code listing is for reference and does not imply coverage or payment.

Provider Actions & Billing Guidance

Documentation Required

Reference member-specific benefit plan

Before deciding coverage, reference the member-specific benefit plan document and applicable federal or state mandates; benefit coverage is determined by the member-specific plan and may differ from this policy.

Documentation Required

Comply with state laws and ADA training requirements

Dentists must comply with applicable state laws, rules, and regulations and follow ADA educational and training requirements for the level of sedation intended, including patient evaluation, personnel and equipment requirements, monitoring and documentation, recovery/discharge, and emergency management.

Definitions

Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation; ventilatory function may be impaired and patients may require an advanced airway. (ASA)

General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation; ventilatory function often impaired and advanced airway/positive pressure ventilation may be required. (ASA)

Local Anesthesia: The elimination of sensation, especially pain, in one part of the body by topical application or regional injection of a drug. (ADA)

Moderate Sedation ('Conscious Sedation'): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands; no interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. (ASA)

Nitrous Oxide: A colorless, odorless to sweet-smelling inorganic gas that when combined with oxygen, can be a safe and effective means of managing pain and anxiety. (ADA)

Non-Intravenous Sedation: Sedation medications that are delivered through the oral, intranasal, or transmucosal routes. (Thomas, 2015)

Background & Clinical References

This policy references guidance from professional organizations including the ADA, AAPD, and ASA and summarizes recommendations applicable to dental office settings.

ADA guidance emphasizes compliance with state laws and educational/training requirements and includes recommendations on patient history/evaluation, personnel and equipment requirements, monitoring and documentation, recovery/discharge, and emergency management.

AAPD guidance notes that pediatric sedation differs from adult sedation and that the in-office use of Deep Sedation or General Anesthesia may be appropriate for select pediatric patients in appropriately equipped and staffed facilities, highlighting higher risks and steps to minimize them.

ASA recommendations focus on appropriate patient selection, quality anesthesia care, and patient safety in dental offices, including pre-procedure evaluation for higher-risk patients, consideration of facility appropriateness for prolonged or extensive procedures, availability of personnel trained in advanced resuscitative techniques, and minimum equipment and emergency protocols.

Revision History

2026-01-01revisedLatest

Definitions amended in policy text (ASA-based definitions). Updated definitions for Deep Sedation and General Anesthesia.

2026-01-01addedLatest

Applicable Codes list updated to reflect annual CDT edits; Added CDT codes D9244, D9245, D9246, and D9247 to applicable codes.

2026-01-01removed

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General Anesthesia and Conscious Sedation Services – Dental Clinical Policyopen_in_new

Coverage Summary

Nitrous Oxide — Indications & Contraindications

Intravenous Moderate/Deep Sedation & General Anesthesia — Indications

Non‑Intravenous Sedation — Indications

General Contraindications for All Types of Sedation and General Anesthesia

Applicable CDT Procedure Codes (reference)

Provider Actions & Billing Guidance

Definitions

Background & Clinical References

Revision History