CurrentEmpire BluecrossPolicy N/A

Inhalation and Local Anesthesia (2021 Policy)

Defines medical necessity, monitoring, documentation, and coverage considerations for local anesthesia, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and nitrous oxide in dental settings. Applies when anesthesia is administered in conjunction with covered dental or medical services and subject to contract/state mandates.

Policy Summary

PayerEmpire Bluecross

PolicyInhalation and Local Anesthesia (2021 Policy)

Policy CodePolicy N/A

Change TypeAnnual review (administrative)

Effective Date01/01/2021

Next Review DateN/A

Key ActionSubmit supporting medical documentation when medical conditions necessitate general anesthesia or conscious sedation and verify member benefits and state mandates.

SourceLink

POLICY UPDATE CHANGES

Policy revised and reviewed 12/06/2020 as annual review by Committee.

Policy entry shows Revised status with publish date 01/01/2021 and last review 12/06/2020.

No material clinical/coverage changes reported in this update.

1Primary clinical guideline

10CDT codes listed (informational)

60Documentation threshold for extended anesthesia (min)

Overview: This policy defines when dental anesthesia services (local, regional/trigeminal block, deep sedation/general anesthesia, intravenous and non-intravenous conscious sedation, and nitrous oxide) are considered medically/dentally necessary and the documentation, monitoring, and contractual requirements that apply. The coverage stance is mixed: anesthesia may be covered when it meets the policy's medical/dental necessity criteria and is provided in conjunction with underlying services that are covered under the dental or medical benefits plan or when required by state mandate.

Note: the listed CDT codes are provided for informational purposes only and inclusion does not guarantee coverage; coverage and reimbursement depend on the member's contract, state mandates, and application of the policy criteria.

Key thresholds and quick facts

Primary clinical guideline1

CDT codes listed (informational)10

Office anesthesia duration documentation threshold> 60 minutes requires written rationale and detailed documentation (associated X-rays, progress notes, operative report, complete anesthesia record with start/stop times)

Anesthesia record required elementsNames/times/dosages of drugs and monitoring of physiological parameters (oxygenation/oximetry, pulse, BP, respirations)

Coverage contingent on underlying serviceAnesthesia covered only in connection with underlying covered dental/medical services or when state mandate applies; check member contract/benefits

OpenPayer

Inhalation and Local Anesthesia (2021 Policy)

Coverage Summary