General Anesthesia (D9500) prior authorization and claims submission guidance
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Governs use of procedure code D9500 for preauthorization submissions and claims for DentaQuest members six years of age and younger; describes required documentation and billing rules and warns that D9500 must not be billed on claims for payment.
No material clinical or coverage changes in this revision.
Coverage and Eligibility for General Anesthesia (D9500)
D9500 preauthorization and payment conditions
Coverage and submission criteria for general anesthesia (D9500) preauthorization for members six years of age and younger.
ALL of the following
- A completed Criteria for Dental Therapy Under General Anesthesia form.
- A completed Prior Authorization Claim Form.
- The location where the procedure(s) will be performed (office, or outpatient hospital/ambulatory setting).
- A tentative date of service if the request is for an outpatient hospital setting.
- A patient-specific narrative detailing: prior treatment history; failed attempts at other levels of sedation; behavior in the dental chair; proposed restorative treatment (tooth ID and surfaces); urgency based on extent of diagnosed dental caries; and any relevant medical condition(s).
- Diagnostic quality radiographs or photographs, or when appropriate images cannot be obtained prior to general anesthesia, a narrative justification explaining inability to perform diagnostic services (note: for cases authorized without preoperative images, diagnostic quality radiographs or photographs will still be required for payment and will be reviewed by the DentaQuest Dental Director).
Procedure Codes and Coverage Status
| D9500 | General anesthesia services (used on preauthorization only when administered by a medical anesthesiologist and/or outpatient setting) |
Preauthorization, Submission, and Claim Billing Rules
Preauthorization submission requirements
Submit D9500 only on the preauthorization when anesthesia will be administered by a Medical Anesthesiologist and/or services are scheduled in an outpatient setting. Include: a completed Criteria for Dental Therapy Under General Anesthesia form; a completed Prior Authorization Claim Form; procedure location (office or outpatient hospital/ambulatory setting); tentative date of service if outpatient hospital request; a patient-specific narrative detailing prior treatment history, failed attempts at other sedation levels, behavior, proposed restorative treatment (tooth ID and surfaces), urgency based on extent of diagnosed caries, and relevant medical conditions; and diagnostic quality radiographs or photographs (or a narrative justification if images cannot be obtained).
- Completed Criteria for Dental Therapy Under General Anesthesia form
- Completed Prior Authorization Claim Form
- Procedure location (office or outpatient hospital/ambulatory setting)
- Tentative date of service if outpatient hospital request
- Patient-specific narrative including prior treatment, failed sedation attempts, behavior, proposed restorative treatment (tooth ID and surfaces), urgency, and relevant medical conditions
- Diagnostic quality radiographs or photographs — or narrative justification if images cannot be obtained
Do not submit D9500 on claims for payment
Do not list D9500 on the claim for payment; claims listing D9500 are subject to denial and the entire claim may be denied if D9500 is submitted.
Definitions and Documentation Requirements
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