CurrentEmpire BluecrossPolicy 09-201

Inhalation and Local Anesthesia (2022 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 inhalation nitrous oxide in dental settings. Applies when anesthesia is provided in conjunction with covered dental or medical services or when state mandates require coverage.

Policy Summary

PayerEmpire Bluecross

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeAnnual review (no material clinical changes)

Effective DateJan 1, 2014

Next Review Date

Key ActionSubmit supporting medical documentation and complete anesthesia records (drug names, times/dosages, physiological monitoring, start/stop times) to support medical necessity and for reviews or claims.

SourceLink

POLICY UPDATE CHANGES

Policy revised with annual review on 10/20/2021.

Revision entries for prior dates (11/12/2020, 12/06/2020, 2/6/2018, etc.) noted in history.

11CDT codes referenced

60Documentation threshold for extended anesthesia

child agePediatric age limit defined by contract

Coverage Summary

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 inhalation nitrous oxide in dental settings. Applies when anesthesia is provided in conjunction with covered dental or medical services or when a state mandate requires coverage. The policy specifies monitoring and documentation requirements, provider training/licensure expectations, indications/contraindications for modalities, and additional documentation requirements for extended office anesthesia (> 60 minutes). The listed CDT codes are provided for informational purposes and their inclusion does not guarantee coverage or payment.

Key thresholds and quick facts

CDT codes referenced11

Documentation threshold for extended anesthesia60 minutes

Pediatric age limit defined by contractchild age

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

Coding (informational)

CDT codes referenced (informational) - codes are informational and do not guarantee coveragemixed

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

1–10 of 12

1/2

Provider Actions & Documentation Requirements

Documentation Required

Support medical necessity with documentation

When general anesthesia or conscious sedation is used for medical conditions, submit supporting documentation from the oral surgeon, dentist and/or physician administering the anesthesia. Include medical records that justify the disability, developmental or medical condition or documentation of failed local anesthesia attempts when applicable.

Documentation Required

Complete anesthesia record required

Maintain and submit a complete anesthesia record when requested for review or claims. The anesthesia record must include the names of all drugs administered, times of administration, dosages, and monitoring of physiological parameters such as pulse oximetry, blood pressure, heart rate and respirations, as well as documented start and stop times.

Prior Authorization

Review for anesthesia services

The plan may perform utilization review and providers should verify the member's contract benefits at the time of service to determine coverage. Some services may also require preauthorization or be subject to state mandate per the member's plan.

Documentation Required

Extra documentation for >60 minute procedures

For office anesthesia that exceeds 60 minutes, provide a written rationale and supporting documentation. Required materials include all associated X‑ray images, progress notes, the operative report, and a complete anesthesia record indicating start and stop times of drug administration.

Background and Policy Scope

This policy states that coverage of anesthesia is generally available only when provided with covered dental or medical services or when required by state mandate, and that benefit determination depends on the member's contract. It emphasizes adherence to recognized standards (including ADA and AAP/AAPD guidance) and requires that dentists administering anesthesia be appropriately educated, trained and licensed. Certain modalities (for example, local anesthesia) are typically considered inclusive of dental procedures and not separately billable unless the plan allows it; regional/trigeminal block may not be covered. Inclusion of CDT codes in the policy is informational and does not constitute or imply member coverage or provider reimbursement.

Medically/Dentally Necessary: Services that are consistent with the member's diagnosis or condition and provided in response to a life‑threatening condition or pain, to treat an injury, illness or infection related to the dentition, or to achieve a level of function to the dentition consistent with prevailing community standards for the diagnosis or condition.

Revision History

10/20/2021revisedLatest

Policy revised with annual review on 10/20/2021.

12/06/2020revised

Version revised (Annual Review) on 12/06/2020.

11/12/2020revised

Version revised (Annual Review) on 11/12/2020.

02/06/2018revised

Version revised on 02/06/2018 for appropriateness and medical necessity.

02/08/2017revision

Version revision dated 02/08/2017.

01/01/2014initial

Initial version published on 01/01/2014.

Policy Summary

PayerEmpire Bluecross

PolicyInhalation and Local Anesthesia (2022 Policy)

Policy CodePolicy 09-201

Change TypeAnnual review (no material clinical changes)

Effective DateJan 1, 2014

Next Review Date

SourceLink

On This Page

OpenPayer

Inhalation and Local Anesthesia (2022 Policy)

Coverage Summary

Medical Necessity and Coverage Criteria

Coding (informational)

Provider Actions & Documentation Requirements

Background and Policy Scope

Revision History