CurrentEmblemHealthPolicy MG.MM.ME.66C6

Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Defines medical necessity criteria, limitations, applicable procedure codes, and billing conditions for general anesthesia and monitored anesthesia care (MAC) for dental and oral/maxillofacial surgical procedures for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyAnesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Policy CodePolicy MG.MM.ME.66C6

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the member meets criteria for treatment or surgical procedure for preauthorization or post-payment review.

POLICY UPDATE CHANGES

No material changes

7Medically Necessary Criteria Items

7Applicable CPT Codes Listed

Coverage Summary

Scope: Defines medical necessity criteria, limitations, applicable procedure codes, and billing conditions for general anesthesia and monitored anesthesia care (MAC) for dental and oral/maxillofacial surgical procedures; policy applies only when the services are covered by the member's benefit plan.

Overview: General anesthesia and MAC are considered medically necessary when the procedure is a covered dental/oromaxillofacial procedure under the member's benefit package and when one or more specified criteria are met (e.g., age ≤6 with complex dental needs, behavioral or medical conditions that impede treatment, allergy to local anesthesia, extensive trauma, excision of bony impacted wisdom teeth).

Medically Necessary Criteria for General Anesthesia and MAC

General anesthesia and MAC are considered medically necessary when the procedure is a covered dental/oromaxillofacial procedure under the member's benefit package AND any one of the following criteria is met:

ALL of the following

Procedure or surgery is covered under the member's benefit package
ONE of
- 1: Member is ≤ 6 years of age 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 combinations of these noted or other dental procedures).
- 2: Member exhibits physical/mental behaviors that would likely impede the successful completion of treatment(s) without the use of anesthesia (e.g., mentally impaired, cerebral palsy, epilepsy, cardiac problems, hyperactivity, etc.).
- 3: Member has severe dental needs, and is uncommunicative, extremely uncooperative, fearful, unmanageable or anxious such that deferment/postponement of treatment would likely result in dental/oral pain, infection, loss of teeth or other increased oral or dental morbidity.
- 4: Allergy or sensitivity to local anesthesia.
- 5: Member has sustained extensive oral-facial/dental trauma for which treatment under local anesthesia would be ineffective or compromised.
- 6: Excision of bony impacted wisdom teeth is required.

Limitations and Exclusions

Anesthesia is covered only when the dental procedure is listed as a covered benefit under the member's benefit package; reimbursement for anesthesia services by the servicing provider will not be paid if not meeting claim/submission requirements.

Nitrous oxide exclusion: Nitrous oxide is excluded when reported on the same date of service as IV sedation, non-IV sedation, or general anesthesia.

Non‑IV sedation restriction: Non‑IV sedation is not allowed on the same day as general anesthesia.

Frequency limit: Coverage of nitrous oxide and intravenous (IV) sedation is limited to once per day, unless more than once is medically necessary for a distinct urgent/emergent procedure performed the same day following recovery from the initial sedation/anesthesia.

Applicable Procedure Codes

Applicable Anesthesia Procedure CodesCPTCovered

00100	Anesthesia for procedures on salivary glands, including biopsy.
00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified.
00172	Anesthesia for intraoral procedures, including biopsy; repair of cleft palate.
00174	Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor.
00176	Anesthesia for intraoral procedures, including biopsy; radical surgery.
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified.
00192	Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism).

Provider Actions and Billing Rules

Documentation Required

Submit clinical evidence for medical necessity

The treating physician or primary care provider must submit clinical evidence that the member meets the criteria for the requested treatment or procedure for preauthorization or for post-payment review; without this documentation EmblemHealth cannot properly review the request.

clinical notes, operative plan, relevant history

Documentation Required

Provider presence and qualifications for MAC

Monitored anesthesia care (MAC) should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as CRNAs or anesthesia assistants) who must be continuously present to monitor the member and must be prepared and qualified to convert to general anesthesia when necessary.

Billing Rule

Medical benefit claim routing

For claims remittance the medical benefit applies when an anesthesiologist, DDS, DMD or Doctor of Medicine in Dentistry submits the claim and the applicable medical necessity criteria are met.

Billing Rule

Local anesthesia included in procedure

Local anesthesia is considered an inclusive component of any dental procedure for pain control and is not separately payable.

Billing Rule

Anesthesia only for covered dental procedures

Anesthesia is covered only for dental procedures listed as covered benefits; reimbursement for anesthesia services by the servicing provider will not be paid per policy wording.

Billing Rule

Nitrous oxide and IV sedation frequency limit

Coverage of nitrous oxide and intravenous (IV) sedation is limited to once per day, unless more than once is medically necessary for a distinct urgent or emergent procedure performed the same day after recovery from the initial sedation or anesthesia.

Billing Rule

Nitrous oxide and sedation mutual exclusion

Nitrous oxide is excluded when reported on the same date of service as IV sedation, non‑IV sedation, or general anesthesia; non‑IV sedation is not allowed on the same day as general anesthesia.

Definitions

Minimal Sedation ('Anxiolysis'): Drug-induced state during which patients respond normally to verbal commands; airway reflexes and ventilatory/cardiovascular functions unaffected.

Moderate Sedation/Analgesia ('Conscious Sedation'): Drug-induced depression of consciousness during which patients respond purposefully to verbal commands; spontaneous ventilation adequate; cardiovascular function usually maintained.

Deep Sedation/Analgesia: 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 assistance maintaining a patent airway.

General Anesthesia: Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation; ventilatory function often impaired and positive pressure ventilation may be required; cardiovascular function may be impaired.

Background

The policy defines levels of sedation consistent with the American Society of Anesthesiologists' continuum (minimal, moderate, deep, and general anesthesia) and states that EmblemHealth's clinical review criteria are based on current literature, guidelines, and expert opinion.

This policy applies only when the services are covered by the member's benefit plan.

Policy Summary

PayerEmblemHealth

PolicyAnesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Policy CodePolicy MG.MM.ME.66C6

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the member meets criteria for treatment or surgical procedure for preauthorization or post-payment review.

On This Page

OpenPayer

Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Coverage Summary

Medically Necessary Criteria for General Anesthesia and MAC

Limitations and Exclusions

Applicable Procedure Codes

Provider Actions and Billing Rules

Definitions

Background

Revision History