CurrentEmpire BluecrossPolicy 09-201

Inhalation and Local Anesthesia (2023 Policy)

Defines medical necessity, coverage conditions, monitoring, documentation, and coding guidance for local anesthesia, regional/trigeminal blocks, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide in dental settings. Applies when anesthesia is provided in conjunction with covered dental or medical services or as required by state mandate.

Policy Summary

PayerEmpire Bluecross

PolicyInhalation and Local Anesthesia (2023 Policy)

Policy CodePolicy 09-201

Change TypeAnnual review (no material changes)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit medical documentation from the oral surgeon, dentist and/or physician documenting the medical conditions that require general anesthesia or conscious sedation.

SourceLink

POLICY UPDATE CHANGES

Policy revised; last revision date indicates annual review on 11/11/2022 with publish effective date 01/01/2023.

MultipleAnesthesia Modalities Addressed

ConditionalCoverage Status

09-201Policy Number

Coverage Summary

Medical-Necessity Criteria and Operational Requirements

Medically Necessary Anesthesia Services

Anesthesia (general, sedation, inhalation) may be covered when provided in conjunction with covered dental services and when medical necessity criteria are met:

ALL of the following

Anesthesia services are provided in connection with underlying services that are covered under the dental or medical benefits plan or when services qualify based on state mandate.
Dentist administering anesthesia must be appropriately educated, trained and licensed; additional individuals trained in Basic Life Support for Healthcare Providers must be present when advanced anesthetics (IV or inhalation) are used.
If required by State, current equipment inspection certificate, sedation license and CPR certification are mandatory.

Criteria to qualify for general anesthesia or conscious sedation benefit

Member must satisfy ONE of the following:

ONE of

Member is a child, up to the age defined by contract, with a dental condition requiring repairs of significant complexity (examples: multiple restorations, pulpal therapy, extractions, combinations of procedures).
Member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia cannot be expected to provide a successful result and which under anesthesia can be expected to produce a superior result; conditions include but are not limited to intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems and hyperactivity (verified by medical documentation).
Member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with complex dental needs which should not be postponed and for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral morbidity.
Local anesthesia is ineffective for the member (e.g., acute infection, anatomic variations, allergy). Failed local anesthesia attempts must be documented and submitted for review.

Local Anesthesia Coverage

Administration of local anesthetic (traditional, electronic, buffered, etc.) is considered inclusive of all dental procedures and is not eligible for a separate benefit unless a specific plan allows coverage.

Regional and Trigeminal Division Block Anesthesia

Regional and trigeminal block anesthesia may not be a covered service.

Provider Actions & Documentation Requirements

Documentation Required

Medical documentation to support need for general anesthesia/ conscious sedation

Submit medical documentation from the oral surgeon, dentist and/or physician documenting the medical conditions that require general anesthesia or conscious sedation (for example: intellectual disability, cerebral palsy, epilepsy, severe cardiac problems).

Documentation Required

Failed local anesthesia documentation

Document and submit failed attempts of local anesthesia administration when claiming general anesthesia or other modalities due to ineffective local anesthesia.

Documentation Required

Anesthesia record and monitoring documentation

Maintain a complete anesthesia record that includes the names of all drugs administered, times of administration and dosages, and all physiological parameters monitored (including pulse oximetry). Monitor and document ventilation (continuous chest movement/respirations) and circulation (blood pressure and heart rate) pre-op, intra-op and post-op.

Documentation Required

Extended anesthesia (>60 minutes) justification

Provide a written rationale and associated supporting documentation for office anesthesia that exceeds 60 minutes. Supporting documentation should include x-rays, progress notes, operative report and a complete anesthesia record with start/stop times and incremental drug administration.

Prior Authorization

Coverage determined by underlying plan/contract and possible state mandates

Verify that the underlying dental or medical benefit plan covers the associated dental services and whether state mandates apply; coverage for anesthesia is generally available only in connection with covered underlying services or when required by state mandate and may be limited by contract.

Denial Risk

Regional/trigeminal block may not be covered

Regional and trigeminal division block anesthesia may not be a covered service; claims for these services may be denied.

D9211
D9212

Coding Guidance (CDT Anesthesia Codes)

CDT Anesthesia Codes (informational)mixed

D9210	local anesthesia not in conjunction with operative or surgical procedures
D9211	regional block anesthesia
D9212	trigeminal division block anesthesia
D9215	local anesthesia in conjunction with operative or surgical procedures
D9219	evaluation for deep sedation or general anesthesia
D9222	deep sedation/general anesthesia - first 15 minutes
D9223	deep sedation/general anesthesia - each 15 minute increment
D9230	inhalation of nitrous oxide/analgesia, anxiolysis
D9239	intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243	intravenous moderate (conscious) sedation/analgesia - each 15 minute increment

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Background and Guideline References

This plan-level dental clinical policy outlines the medical necessity and appropriateness for use of local anesthesia, regional/trigeminal division blocks, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and inhalation nitrous oxide in dental practice. It emphasizes that dentists administering anesthesia must be appropriately educated, trained and licensed, that additional individuals trained in Basic Life Support for Healthcare Providers are required when advanced anesthetics (IV or inhalation) are used, and that monitoring, emergency management, and complete anesthesia documentation (drugs, times, dosages, pulse oximetry, ventilation and circulation assessments) are mandatory.

Anesthesia coverage is tied to underlying covered dental or medical services or state mandates and may be limited by contract; office anesthesia exceeding 60 minutes requires written rationale and complete supporting documentation. Referenced guideline sources include the American Dental Association (ADA), American Academy of Pediatrics/American Academy of Pediatric Dentistry (AAP/AAPD), American Society of Anesthesiologists (ASA), and American Association of Oral and Maxillofacial Surgeons (AAOMS) for practice, monitoring and safety standards.

Definitions & Evidence

Definition - Medically/Dentally NecessaryServices consistent with the member's diagnosis or condition, rendered in response to life-threatening condition or pain, to treat dentition-related illness/injury, or to achieve function consistent with community standards; not cosmetic or primarily for convenience.

Evidence / Guideline sourcesADA, AAP, AAPD, ASA, AAOMS referenced for monitoring and practice standards

Policy Summary

PayerEmpire Bluecross

PolicyInhalation and Local Anesthesia (2023 Policy)

Policy CodePolicy 09-201

Change TypeAnnual review (no material changes)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit medical documentation from the oral surgeon, dentist and/or physician documenting the medical conditions that require general anesthesia or conscious sedation.

SourceLink

On This Page

OpenPayer

Inhalation and Local Anesthesia (2023 Policy)

Coverage Summary

Medical-Necessity Criteria and Operational Requirements

Provider Actions & Documentation Requirements

Coding Guidance (CDT Anesthesia Codes)

Background and Guideline References

Revision History