CurrentDelta Dental of OhioPolicy 282.20.v2

Clinical Criteria for Anesthesia and Intravenous Sedation

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Establishes clinical criteria for determining the medical necessity and clinical appropriateness of general anesthesia, deep sedation, and intravenous moderate conscious sedation provided with dental procedures.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Anesthesia and Intravenous Sedation

Policy CodePolicy 282.20.v2

Change TypeNo material clinical or coverage change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionDocument at least one qualifying indication and submit the treatment plan, medical-necessity narrative, required radiographs, and anesthesia or sedation record when authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Applicable CDT procedure codes

1 hourExtended-session documentation threshold

3 years or youngerPediatric age criterion

6General clinical indication categories

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CurrentDelta Dental of OhioPolicy 282.20.v2

Clinical Criteria for Anesthesia and Intravenous Sedation

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Sign up for deltadentalofohio Policy 282.20.v2 alerts

Get alerted when Policy 282.20.v2 changes without checking for updates manually.

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Anesthesia and Intravenous Sedation

Policy CodePolicy 282.20.v2

Change TypeNo material clinical or coverage change

Effective DateJun 21, 2025

Next Review DateNot specified

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Applicable CDT procedure codes

1 hourExtended-session documentation threshold

3 years or youngerPediatric age criterion

6General clinical indication categories

4Safety documentation domains

Medical Necessity and Coverage Criteria

General medical necessity indications

Anesthesia or sedation may be considered medically necessary and clinically appropriate when at least one generally accepted indication is documented.

Qualifying clinical indication

Physical compromising condition: Inability to obtain adequate pain control with local anesthesia, allergy to local anesthetics, or another known contraindication to local anesthesia.
Medical compromising condition: Disease or condition with severe spasticity, closed head trauma, stroke, or another condition causing inability to cooperate with directions.
Behavioral or psychological compromising condition: Behavioral, intellectual, cognitive, emotional, or psychological condition requiring depression of consciousness, anxiety, or pain to safely and efficaciously perform required dental treatment.
Complex dental procedure: A long, extensive, or complex procedure necessary to treat the dental condition, such as surgical removal of teeth involving multiple quadrants or a procedure in which unexpected movement could compromise the treatment outcome.
Young or uncooperative patient: Young patient with limited understanding, anxiety, or uncooperative behavior when alternate nonpharmacologic control methods are not safe and effective.
Other safety-related condition: Another condition in which medically necessary dental treatment cannot be safely provided without anesthesia or intravenous sedation.

Appendix A authorization criteria

Requests for general anesthesia or intravenous sedation will be authorized for procedures covered by the Health Plan when at least one of the following criteria is met.

Extensive or complex oral surgery: The procedure is an extensive or complex oral surgical procedure, including impacted wisdom teeth, surgical root recovery from the maxillary antrum, surgical exposure of impacted or unerupted cuspids, or radical excision of lesions in excess of 1.25 cm.
Medical condition requiring monitoring: The patient has a medical condition requiring monitoring, such as cardiac problems or severe hypertension.
Hazardous underlying medical condition: The patient has an underlying hazardous medical condition, such as cerebral palsy, epilepsy, or mental retardation including Down's syndrome, that would render the patient non-compliant.
Failed sedation or ineffective local anesthesia:

Administration and safety requirements

When anesthesia or sedation is used, care must comply with applicable professional and governmental requirements.

Anesthesia and sedation quality requirements: The practitioner must be appropriately educated, trained, licensed, and qualified; obtain written informed consent and provide preprocedure instructions; perform and document an appropriate physical assessment; use properly maintained equipment and supplies; maintain emergency life-support protocols, age-appropriate equipment, drugs, and positive-pressure oxygen capability; continuously monitor consciousness, ventilation, oxygenation, and circulation as appropriate; provide appropriate recovery and discharge processes; and maintain an accurate, contemporaneous anesthesia/sedation record.

Pediatric cases additionally require compliance with applicable AAPD and ASA guidance, including appropriate monitoring and rescue capability.

General anesthesia or IV sedation authorization

General anesthesia or IV sedation will be authorized for procedures covered by the Health Plan when any qualifying criterion is met.

Qualifying authorization criteria

Extensive or complex oral surgical procedure: The procedure is extensive or complex oral surgery, such as impacted wisdom teeth; surgical root recovery from the maxillary antrum; surgical exposure of impacted or unerupted cuspids; or radical excision of lesions in excess of 1.25 cm.Lesion greater than 1.25 cm for the listed lesion-excision example
Medical or clinical indication: A medical condition requires monitoring, such as cardiac problems or severe hypertension; an underlying hazardous medical condition would render the patient non-compliant, including cerebral palsy, epilepsy, or mental retardation including Down's syndrome; sedation has previously failed; severe periapical infection would render local anesthesia ineffective; or the patient is 3 years old or younger and requires extensive procedures.Patient age 3 years old and younger for the pediatric criterion

Procedure-related anesthesia coverage

Anesthesia is generally covered for surgical or restorative procedures and may also be covered for a nonsurgical procedure when the patient would be unable to undergo it without sedation.

Covered treatment setting: The anesthesia or sedation is used for a surgical or restorative procedure, or is necessary for the patient to undergo a nonsurgical procedure.

General anesthesia must be administered by an eligible provider for coverage under the stated code provisions.

Anesthesia or intravenous sedation used solely for the convenience of the patient or practitioner is not considered medically necessary or clinically appropriate. The dental record must support a qualifying patient or treatment-related indication.

Anesthesia or intravenous sedation is not supported when safe and effective alternatives to anesthesia, sedation, or the planned dental procedure are available and expected to meet the patient's dental needs. Nonpharmacologic methods should be considered when they can safely and effectively control behavior, pain perception, or movement.

Plan-specific dental benefit criteria and limitations control the medical-necessity review. Coverage may be excluded when anesthesia or intravenous sedation is performed in conjunction with dental services that are not covered under the applicable benefit program.

The cost of analgesic and local anesthetic agents is included in the fees for covered dental services reimbursed by the Medicaid program and is not reimbursed separately.

Care that is not complicated by a qualifying patient or treatment condition and can be safely and efficaciously rendered without anesthesia or intravenous sedation is generally considered not medically necessary or clinically appropriate.

Anesthesia or sedation may be determined not medically necessary when the dental procedure for which it was used is not documented, when the associated dental procedure was not medically necessary or clinically appropriate, or when the diagnosis and reported anesthesia or sedation procedure are not supported by the patient record.

Anesthesia or sedation whose duration exceeds the treatment time required for the patient's condition or dental treatment may be determined not medically necessary. Sessions lasting more than 1 hour require credible clinical documentation supporting the particular need for the additional time.

Certain medical conditions, airway issues, or serious comorbidities may present relative contraindications to particular anesthesia or sedation settings and regimens used for dental procedures. The selected setting and regimen must be appropriate to the patient's clinical risk and treatment needs.

Applicable Codes and Coding Rules

Applicable CDT Procedure 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

Deep sedation/general anesthesiaCDTCovered

D9222

Deep sedation/general anesthesia -first 15 minutes

Deep sedation/general anesthesiaCDTCovered

D9223

Deep sedation/general anesthesia -each 15 minute increment

Intravenous moderate (conscious) sedation/analgesiaCDTCovered

D9239

Intravenous moderate (conscious) sedation/analgesia-first 15 minutes

Intravenous moderate (conscious) sedation/analgesiaCDTCovered

D9243

Intravenous moderate (conscious) sedation/analgesia-each 15 minutes increment

Anesthesia or sedation session duration

Duration thresholdMore than 1 hour

Documentation requirementClinical documentation must provide credible evidence of the particular need for the additional time.

Example supporting circumstanceExtra anesthesia or sedation time required for special-needs patients.

Pediatric age for extensive procedures

Age criterion3 years old and younger

Treatment requirement

Authorization, Documentation, and Provider Requirements

Prior Authorization

Authorization and Submission Requirements

Submit authorization requests for general anesthesia or IV sedation for procedures covered by the member’s health plan. Include the treatment plan, when required, and a narrative explaining medical necessity; emergency treatment rendered before authorization remains subject to claim review with these materials.

Authorization applies only to procedures covered by the health plan.
Emergency treatment performed when authorization is not possible still requires the treatment plan and medical-necessity narrative with the claim.

Documentation Required

Document a Qualifying Indication

When benefit payment requires medical-necessity and clinical-appropriateness review, document a generally accepted indication for anesthesia or sedation in the patient’s dental record. Qualifying indications include physical, medical, behavioral, cognitive, emotional, psychological, procedural, or age-related circumstances that prevent safe and effective treatment without anesthesia or IV sedation.

Policy Background

Anesthesia and intravenous sedation may be used with dental treatment when the patient's condition or the complexity of treatment prevents care from being safely, humanely, and efficaciously delivered without control of behavior, pain perception, or movement. The appropriate route, depth, and duration depend on the dental treatment and the patient's condition. Services may be provided by qualified clinicians in appropriately equipped offices, ambulatory surgery centers, or hospital operating rooms, depending on patient risk and treatment needs.

Sedation and Anesthesia Definitions

Minimal sedation

Level of consciousnessA minimally depressed level of consciousness produced pharmacologically.

Airway and responseThe patient can independently and continuously maintain an airway and respond normally to tactile stimulation and verbal commands.

Physiologic functionVentilatory and cardiovascular functions are unaffected.

Moderate sedation

Level of consciousnessA drug-induced depression of consciousness.

Patient responseThe patient responds purposefully to verbal commands, with or without light tactile stimulation.

Airway and ventilation

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Anesthesia and Intravenous Sedation

Policy CodePolicy 282.20.v2

Change TypeNo material clinical or coverage change

Effective DateJun 21, 2025

Next Review DateNot specified

SourceLink

On This Page

The patient has documented failed sedation or a condition in which severe periapical infection would render local anesthesia ineffective.

Very young patient with extensive treatment: The patient is 3 years old or younger and extensive procedures are to be accomplished.3 years old and younger

Extensive procedures are to be accomplished.

Authorization contextThis is a qualifying criterion for general anesthesia or intravenous sedation when the procedure is covered by the Health Plan.

Radical excision lesion size

Lesion size thresholdIn excess of 1.25 cm

Procedure categoryRadical excision of lesions is listed as an extensive or complex oral surgical procedure.

Authorization contextThe procedure may qualify for general anesthesia or intravenous sedation when the procedure is covered by the Health Plan.

Radical excision lesion size

Lesion size thresholdIn excess of 1.25 cm

Procedure categoryRadical excision of lesions is listed as an extensive or complex oral surgical procedure.

Authorization contextThe procedure may qualify for general anesthesia or intravenous sedation when the procedure is covered by the Health Plan.

Patient age for extensive procedures

Patient age criterion3 years old and younger

Treatment requirementExtensive procedures are to be accomplished.

Clinical review contextThe criterion is included among the medical conditions supporting authorization for general anesthesia or intravenous sedation.

Sedation/anesthesia billing increment

Initial billing incrementFirst 15 minutes

Subsequent billing incrementEach subsequent 15-minute increment, as specified by code.

Applicable servicesDeep sedation/general anesthesia and intravenous moderate (conscious) sedation/analgesia.

Examples include inability to obtain adequate pain control with local anesthesia, contraindication or allergy to local anesthetics, severe spasticity, closed head trauma or stroke, inability to cooperate, extensive or complex treatment, and young age with unsafe or ineffective nonpharmacologic control.
Government requirements and member-plan provisions defining medical necessity and coverage may take precedence.

Prior Authorization

Authorization Requires a Qualifying Criterion

Authorization for general anesthesia or IV sedation is available for covered procedures when at least one qualifying criterion is documented. The record must connect the requested anesthesia or sedation to the covered treatment and the patient’s clinical circumstances.

Extensive or complex oral surgery may qualify, including impacted wisdom teeth, surgical root recovery from the maxillary antrum, exposure of impacted or unerupted cuspids, or radical excision of lesions exceeding 1.25 cm.
Other qualifying circumstances include a medical condition requiring monitoring, a hazardous underlying condition causing noncompliance, documented failed sedation, severe periapical infection making local anesthesia ineffective, or a patient age 3 or younger requiring extensive procedures.

Documentation Required

Show That Alternative Methods Are Inadequate

Use anesthesia or sedation only when controlling patient behavior, pain perception, or movement cannot be safely and effectively managed with alternate nonpharmacologic methods. Document why those alternatives and/or planned dental procedures are inadequate for the patient’s needs.

Do not request anesthesia or sedation solely for patient or practitioner convenience.
Consider whether safe and effective alternatives are available and whether the planned dental treatment can be provided without anesthesia or IV sedation.

Documentation Required

Submit Required Clinical Records

Maintain and submit the clinical records needed for medical-necessity and clinical-appropriateness review. If requested records cannot be provided, benefit payment may be disapproved.

Current diagnostic radiographs showing the area(s) of proposed or rendered treatment.
Treatment plan documenting the diagnostic rationale for treatment requiring anesthesia or IV sedation.
Record documenting why anesthesia or IV sedation was medically necessary, plus the anesthesia/sedation record.

Documentation Required

Support Extended Treatment Time

Support any anesthesia or sedation session exceeding one hour with credible clinical documentation showing the particular need for the additional time.

Examples may include additional anesthesia or sedation time required for a patient with special needs.

Documentation Required

Maintain the Anesthesia and Sedation Record

Keep an accurate, contemporaneous anesthesia or sedation record for every procedure. The record must demonstrate informed consent, qualified personnel, appropriate assessment, treatment, monitoring, and disposition.

Document anesthesia/sedation team members; preprocedure assessment; drugs, dosages, and administration times; intraoperative and postoperative monitoring; complications; discharge details; and postoperative communication.
Obtain written informed consent and provide information about agents, benefits, risks, alternatives, and preprocedure instructions.

Documentation Required

Document Safety and Care Delivery

Document that anesthesia or sedation was delivered in a safe, guideline-consistent manner from consent through discharge. The record and care process must support appropriate assessment, equipment, emergency readiness, monitoring, recovery, and post-operative instructions.

Complete a physical preprocedure assessment covering medical history, medications, prior anesthesia or sedation problems, baseline vital signs, and conditions increasing risk; consult relevant physicians when indicated.
Check and maintain equipment and supplies, maintain age-appropriate emergency protocols and positive-pressure oxygen, and continuously monitor consciousness, ventilation, oxygenation, and circulation as appropriate.
Document recovery and satisfactory discharge, provide verbal and written instructions, and release the patient to a responsible person.

Documentation Required

Meet Pediatric Sedation Requirements

For pediatric sedation, use agents and practices appropriate for children and ensure the team can recognize and respond to changing sedation depth and airway emergencies. Follow applicable AAPD and ASA guidance for the level of sedation and the setting.

Administering clinicians must understand pediatric pharmacokinetics, pharmacodynamics, drug interactions, and sedation levels.
A qualified individual not directly performing the dental treatment must continuously observe the child and conduct appropriate physiologic monitoring; advanced pediatric life-support competency is required.
The team must be able to rescue a child with apnea, laryngospasm, or airway obstruction, including airway opening, suction, CPAP, and bag-valve-mask ventilation.

Documentation Required

Document the Qualifying Clinical Indication

Document the specific qualifying clinical circumstance supporting anesthesia or IV sedation, including failed sedation or a condition that makes local anesthesia ineffective. The diagnosis and reported anesthesia or sedation procedure must be supported by the patient record.

Record the relevant medical, behavioral, cognitive, emotional, psychological, physical, procedural, or age-related indication.
If relying on failed sedation, severe periapical infection, or another condition, include contemporaneous clinical evidence.

Denial Risk

Avoid Circumstances That May Result in Disapproval

Benefits may be disapproved when treatment or the patient’s circumstances do not meet the clinical criteria for anesthesia or sedation. Review the record for a genuine clinical need before submitting.

Care that is not complicated by a qualifying condition and can be safely and effectively provided without anesthesia or IV sedation is nonqualifying.
Claims may be disapproved when anesthesia or sedation is not linked to documented treatment, is submitted with non-medically necessary treatment, lasts longer than clinically required, is for convenience, or lacks record support.
Certain medical conditions, airway issues, or serious comorbidities may create relative contraindications to the selected setting or regimen.

Denial Risk

Prevent Safety or Qualification-Based Denials

Failure to comply with anesthesia and sedation safety requirements, or administration by an individual who is not appropriately licensed and qualified, results in denial of benefit payment and referral to the appropriate regulatory agency.

Verify licensing, qualifications, training, emergency readiness, monitoring, and compliance with applicable statutes, regulations, and professional guidance.

Billing Rule

Check Plan-Specific Limitations

Apply the member’s dental benefit program criteria and limitations when evaluating medical necessity and eligibility for anesthesia or IV sedation. Program-specific rules may limit coverage, including when anesthesia or sedation is provided with noncovered services.

Government requirements and the member’s plan may take precedence over these clinical criteria.
Review plan-specific benefit criteria before requesting authorization or billing.

Denial Risk

Missing Documentation Can Cause Disapproval

Delta Dental of Ohio may request radiographs, treatment-plan rationale, the medical-necessity indication, anesthesia/sedation records, and other relevant clinical information. If required documentation is missing or cannot be supplied, benefit payment may be disapproved.

Submit additional clinical information when requested to support the coverage decision.
Ensure the diagnosis, treatment, anesthesia or sedation procedure, and duration are consistent across the record and claim.

Denial Risk

No Covered Procedure or Qualifying Indication

Authorization or payment may be denied when there is no covered dental procedure or no documented qualifying indication for anesthesia or IV sedation. Sedation is not payable when the associated treatment is noncovered, medically unnecessary, clinically inappropriate, or can be safely completed without it.

Confirm that the planned procedure is covered under the member’s health plan.
Document at least one qualifying criterion and the clinical reason anesthesia or IV sedation is required.

Billing Rule

Use Eligible Providers and Observe Bundled-Agent Rules

Bill covered anesthesia and sedation services only when administered by an eligible, appropriately licensed provider and in accordance with plan rules. Analgesic and local anesthetic agents are bundled into covered dental-service fees under the applicable program and are not reimbursed separately.

D9222 and D9223 deep sedation/general anesthesia may be reimbursed separately from covered dental procedures; payment is a fixed amount of one unit per patient per date of service regardless of time or units billed.
D9239 and D9243 intravenous moderate sedation/analgesia are paid at a fixed amount per patient per date of service.
Anesthesia is generally covered for surgical or restorative procedures and may also be payable when sedation is necessary for a nonsurgical procedure.

No airway intervention is required, and spontaneous ventilation is adequate.

Deep sedation

Level of consciousnessA drug-induced depression of consciousness in which the patient cannot be easily aroused.

Response to stimulationThe patient responds purposefully after repeated or painful stimulation.

Airway and ventilationIndependent ventilation may be impaired; airway assistance may be required, and spontaneous ventilation may be inadequate.

General anesthesia

Level of consciousnessA drug-induced loss of consciousness.

Response to stimulationThe patient is not arousable, even by painful stimulation.

Airway and ventilationIndependent ventilation is often impaired; airway assistance and positive-pressure ventilation may be required.