CurrentEmblemHealthPolicy MG.MM.ME.66C7

Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Defines medical necessity criteria, limitations, and applicable procedure codes for general anesthesia and monitored anesthesia care (MAC) for dental and oral/maxillofacial procedures when the procedure is a covered benefit under the member's plan.

Policy Summary

PayerEmblemHealth

PolicyAnesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Policy CodePolicy MG.MM.ME.66C7

Change TypeNo material change

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the member meets the criteria for the treatment or surgical procedure for preauthorization or post-payment review; without this documentation EmblemHealth will not review the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified in this brief (has_material_change=false).

6Listed Medical Necessity Criteria

7Applicable CPT Codes

1Policy Number

Coverage Summary

Medically Necessary Indications for General Anesthesia or MAC

General anesthesia and MAC are considered medically necessary when the procedure is a covered benefit and ANY of the following criteria are met:

ANY of the following

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).
Member exhibits physical or mental behaviors that would likely impede the successful completion of treatment(s) without the use of anesthesia (examples: mentally impaired, cerebral palsy, epilepsy, cardiac problems, hyperactivity).
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.
Allergy or sensitivity to local anesthesia.
Member has sustained extensive oral-facial/dental trauma for which treatment under local anesthesia would be ineffective or compromised.
Excision of bony impacted wisdom teeth is required.

Definitions and Background

Defines levels of sedation per the American Society of Anesthesiologists: Minimal Sedation (Anxiolysis), Moderate Sedation/Analgesia (Conscious Sedation), Deep Sedation/Analgesia and General Anesthesia. EmblemHealth bases the criteria on current clinical literature and professional guidelines and uses these definitions to determine medical necessity for anesthesia in dental and oral/maxillofacial surgery.

Term	Definition
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.
General Anesthesia	Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation; ventilatory function often impaired and cardiovascular function may be impaired.
Minimal Sedation (Anxiolysis)	Drug-induced state during which patients respond normally to verbal commands; airway reflexes and ventilatory/cardiovascular functions are unaffected.
Moderate Sedation/Analgesia (Conscious Sedation)	Drug-induced depression of consciousness during which patients respond purposefully to verbal commands; no interventions are required to maintain airway; spontaneous ventilation adequate.

Evidence summary: EmblemHealth's criteria reference professional guideline sources including the American Academy of Pediatric Dentistry, American Academy of Pediatrics, American Society of Anesthesiologists and the American Dental Association (guidelines and policy statements cited, with references through 2023 and accessed May 12, 2026).

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

Prior Authorization

Documentation required for medical necessity review

Treating physician or primary care provider must submit clinical evidence that the member meets the criteria for the treatment or surgical procedure for preauthorization or post-payment review; without this documentation EmblemHealth will not review the request.

Billing Rule

Provider/claim submission rules

Medical benefit applies if an anesthesiologist, DDS/DMD, or Doctor of Medicine in Dentistry submits the claim and criteria are met; reimbursement for anesthesia services by the servicing provider will not be paid (clarifies pay-to rules).

Billing Rule

Nitrous oxide and IV/non-IV sedation same-day limits

Coverage of nitrous oxide and intravenous (IV) sedation is limited to once per day; nitrous oxide is excluded when reported on 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.

Documentation Required

Qualified personnel and monitoring for MAC

Monitored anesthesia care (MAC) should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as CRNAs or anesthesia assistants) who are continuously present and must be prepared and qualified to convert to general anesthesia when necessary, consistent with ASA standards.