CurrentDenver-Health-Medical-PlanPolicy N/A

Dental-Related General Anesthesia and Facility Charges

Defines medical necessity criteria for coverage of general anesthesia and associated facility charges for dental services across Commercial, Medicaid and CHP+ lines of business. Applies to hospital or outpatient surgical settings and alternate facilities when anesthesia is provided by a provider other than the dentist.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyDental-Related General Anesthesia and Facility Charges

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvide appropriate medical documentation to verify physical, intellectual, or medically compromising conditions when asserting coverage under the listed medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

7Listed medical necessity criteria

2Key CPT codes listed

30+ICD-10 codes / ranges cited

Coverage Summary

This policy covers with criteria the medical/surgical benefit payment of general anesthesia and associated facility charges for dental services across Commercial, Medicaid, and CHP+ lines of business. It applies when care is delivered in a hospital or outpatient surgical setting, and also applies to designated alternate facilities (freestanding centers such as ambulatory surgical centers) when the anesthesia is provided by a provider other than the dentist.

Medically Necessary Criteria for General Anesthesia & Facility Charges

Medically Necessary Criteria for Coverage of General Anesthesia and Facility Charges

Covered when ANY one of the following is met:

ANY of the following

Patients, including infants, exhibiting physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and which, under general anesthesia, can be expected to produce a superior result.
Conditions include but are not limited to mental retardation, cerebral palsy, epilepsy, cardiac problems, and hyperactivity; verification by appropriate medical documentation required.
Extremely uncooperative, fearful, anxious patients, or patients with dental needs of such magnitude that treatment should not be postponed or deferred and whose lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity.
A total of six or more teeth are extracted in various quadrants.>= 6 teeth extracted in various quadrants
Dental treatment needs for which local anesthesia is ineffective because of acute infection, anatomic variation, or allergy.
The member is a child under the age of seven years old with a dental condition that requires repairs of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions, or any combination).< 7 years old
Patients with a concurrent hazardous medical condition.
Extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.

Provider requirement

The anesthesia must be rendered by a provider other than the provider performing the dental service.
All facility charges incurred in association with the anesthesia charges are covered under the medical/surgical benefit when any one of the above criteria are met.

Coding

Anesthesia CPTCPTCovered

00170

Unlisted anesthesia procedure(s)

Facility charge / dental procedure CPTCPTCovered

41899

Other Procedures on the Dentoalveolar Structures

ICD-10 diagnosis codes (examples supporting coverage criteria)ICD-10

F43.0	Acute stress reaction
308.3	Acute stress reaction (alternate format listed)
F90.1	Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2	Attention-deficit hyperactivity disorder, combined type
F90.9	Attention-deficit hyperactivity disorder, unspecified type
F95.2	Tourette's disorder
F70	Mild intellectual disabilities
F79	Unspecified intellectual disabilities
G80.0	Spastic quadriplegic cerebral palsy
G80.1	Spastic diplegic cerebral palsy

1–10 of 33

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Provider Actions & Billing Rules

Documentation Required

Medical documentation for qualifying conditions

Provide appropriate medical documentation to verify physical, intellectual, or medically compromising conditions when asserting coverage under criterion A.1. Verification should reference the member's condition and how local anesthesia is unlikely to produce a successful result but general anesthesia can be expected to produce a superior result.

Mental retardation / intellectual disability (e.g., F70, F79)
Cerebral palsy (e.g., G80.0–G80.9)
Epilepsy (e.g., G40.* ranges listed)
Cardiac problems (as noted in clinical criterion)
Hyperactivity / severe ADHD (e.g., F90.1–F90.9)

Billing Rule

Anesthesia provider separation requirement

Anesthesia must be rendered by a provider other than the provider performing the dental service. Facility charges incurred in association with the anesthesia charges are covered under the medical/surgical benefit only when this provider separation requirement and any one of the listed medical necessity criteria are met.

Affected codes: CPT 00170 (Unlisted anesthesia procedure(s)), CPT 41899 (Other Procedures on the Dentoalveolar Structures)
Operational requirement: Facility charges are covered only when anesthesia is provided by a separate provider (not the dental provider) and at least one medical necessity criterion from the policy is met

Definitions & Background

Policy clarifies that general anesthesia and associated facility charges for dental procedures are considered medical/surgical benefits when any one of the listed clinical criteria is met and the anesthesia is rendered by a provider other than the provider performing the dental service. Applicable settings include hospital and outpatient surgical settings and Alternate Facilities (freestanding, non‑hospital sites designated by the hospital, e.g., ambulatory surgical centers).

Definitions note that General Anesthesia is drug‑induced loss of consciousness with impaired ventilatory and potentially cardiovascular function, and that an Alternate Facility is a freestanding health care facility that is not a physician's or dentist's office and is not attached to a hospital.

References: ADA Guidelines for the use of sedation and general anesthesia by dentists (2016); Journal article: The use of general anesthesia to facilitate dental treatment in adult patients with special needs (2017).

Definitions

Evidence / References