CurrentFidelis CarePolicy CP.FC.02

Dental Anesthesia and Facility Services

Defines when IV moderate sedation, IV deep sedation, and general anesthesia for dental procedures performed in office, hospital, or ambulatory surgical center are medically necessary or not medically necessary for Fidelis Care members (all lines of business except Medicare). Also describes provider qualification, facility considerations, drugs used, and coding implications.

Policy Summary

PayerFidelis Care

PolicyDental Anesthesia and Facility Services

Policy CodePolicy CP.FC.02

Change TypeRevisions; LOB update

Effective Date

Next Review Date

Key ActionAuthorization must be obtained per Fidelis Care process and for Medicaid LOB the Dental Vendor approval for the dental/orthodontic procedure must accompany anesthesia/sedation requests.

SourceLink

POLICY UPDATE CHANGES

Annual Review. Rewording of medically necessary conditions with no impact to criteria. Rewording of not medically necessary conditions. Rewording of background section.

Revised LOB to exclude Medicare and included new CPT code G0330.

Added CPT code 21299 (unlisted craniofacial and maxillofacial procedure).

10Medically necessary criteria listed

8Not medically necessary conditions listed

3Supporting CPT/G-code entries

Coverage Summary

This policy defines medical necessity criteria and administrative processes for providing IV moderate sedation, IV deep sedation, and general anesthesia for dental procedures performed in office, hospital, or ambulatory surgical center settings (all lines of business except Medicare). It emphasizes pediatric considerations — including a higher risk of adverse outcomes in children and specific age-based thresholds — and delineates provider qualifications, monitoring and facility considerations, and coding/authorization implications (including supporting CPT/G-code entries).

Policy-level key facts

Age threshold< 8 years

Number of restorative procedures threshold> 4 restorative procedures

Policy numberCP.FC.02

Coverage stancemixed

StatusCURRENT

Reference count18 citations

Medically Necessary and Not Medically Necessary Criteria

Medically necessary criteria for IV moderate sedation, IV deep sedation, and general anesthesia

Covered when ANY of the following are met:

ANY of the following

Age younger than eight (8) years 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 combination of these or other dental procedures)< 8 years
Documented extreme anxiety or fear and documentation of failed local anesthesia, inhalation of nitrous oxide, or oral conscious sedation attempts
Dental and medical records documentation substantiates a physical, cognitive, or developmental disability (including, but not limited to, congenital cardiac defect, cerebral palsy, epilepsy) that would render the patient non-compliant

Coding

CPT codes that support coverage criteriaCPTCovered

41899	Unlisted procedure, dentoalveolar structures
21299	Unlisted craniofacial and maxillofacial procedure
G0330	Facility Services for dental rehabilitation procedures performed on a patient who requires monitored anesthesia (i.e. general, intravenous sedation) and use of an operating room

Provider Actions and Authorization

Prior Authorization

Authorization required for anesthesia/facility services

Authorization must be obtained per the Fidelis Care process for anesthesia and facility services. For Medicaid line of business, approval of the requested dental/orthodontic procedure by the Dental Vendor must accompany anesthesia or IV sedation requests or the request will be denied.

G0330
41899
21299

Documentation Required

Clinical documentation to support medical necessity

Document clinical information that supports medical necessity in the dental and medical records, including patient age, behavioral status, prior failed sedation attempts, medical or physical disabilities, allergies to local anesthesia, complexity and quantity of procedures, or other underlying medical conditions.

Background, Evidence, and Definitions

The policy aligns with guidance from the American Dental Association (ADA), American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Society of Anesthesiologists (ASA) and other professional organizations, and references peer-reviewed literature. It stresses that pediatric sedation differs from adult sedation and that high-risk and pediatric patients (particularly those under age 8) should be evaluated by a primary care physician or physician anesthesiologist prior to scheduling when indicated.

The policy requires that sedation/anesthesia be administered by a qualified anesthesia provider (medical anesthesiologist, CRNA, dentist anesthesiologist, or second oral surgeon) with PALS skills, with a skilled, PALS-certified second observer present for deep sedation/general anesthesia in the office setting. It also outlines facility considerations (including when office-based care may be inappropriate for prolonged/extensive procedures) and lists common drugs used for anxiolysis, oral conscious sedation, IV moderate sedation, and IV deep sedation/general anesthesia. CPT codes that support coverage criteria (e.g., 41899, 21299, and G0330) are included for authorization and coding implications.

Evidence summary

Reference count18 citations including ADA, AAPD, AAP, ASA guidance and peer-reviewed literature

IV Moderate Sedation: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, no airway interventions required, spontaneous ventilation adequate, cardiovascular function usually maintained.

Revision History

1/24non-material (revised)

Annual Review. Rewording of medically necessary conditions with no impact to criteria. Rewording of not medically necessary conditions. Rewording of background section.

1/25material (revised)

Annual review: Revised LOB to exclude Medicare and included new CPT code G0330.

12/20non-material (added)

Added CPT code 21299 (unlisted craniofacial and maxillofacial procedure).

Policy Summary

PayerFidelis Care

PolicyDental Anesthesia and Facility Services

Policy CodePolicy CP.FC.02

Change TypeRevisions; LOB update

Effective Date

Next Review Date

Key ActionAuthorization must be obtained per Fidelis Care process and for Medicaid LOB the Dental Vendor approval for the dental/orthodontic procedure must accompany anesthesia/sedation requests.

SourceLink

On This Page

Underlying medical conditions are supported by patient records

There is documentation of allergy or sensitivity to local anesthesia

Lengthy and numerous (more than four) restorative procedures for pediatric member/enrollee> 4 restorative procedures

Documentation indicates a pediatric member/enrollee has resisted all other conventional behavior management procedures

Documentation indicates a pediatric member/enrollee has history of uncooperative behaviors that may result in the compromised safety of the member/enrollee, provider, or staff

Documented history of relevant social impact conditions

Complex and extensive surgical procedures such as two or more impacted teeth in two or more quadrants, or two or more extractions of permanent teeth per quadrant in at least two quadrants

Not medically necessary criteria for inpatient or ambulatory surgery center when services are not available in provider office

Not medically necessary when ANY of the following apply:

ANY of the following

Member/enrollee has predisposing medical and/or physical conditions that would make general anesthesia unsafe
Member/enrollee is cooperative and has minimal dental needs
General anesthesia or moderate or deep sedation is requested for member/enrollee or dentist convenience
Member/enrollee has history of tolerating similar dental procedures without the need for sedation
Member/enrollee has a choice of an alternative option for treatment
Member/enrollee has an allergy to oral sedatives or reversal agents
Parent or guardian objects to the sedation or general anesthesia
There are no covered and approved dental services to be rendered

Medicaid-specific denial criteria

For Medicaid line of business only, requests for general anesthesia or IV sedation in an inpatient setting or ambulatory surgery center will be denied when ANY of the following apply:

ANY of the following

Approval of requested dental/orthodontic procedure has not been approved by the Dental Vendor as medically necessary
Approval by the Dental Vendor for requested dental/orthodontic procedure is not submitted with general anesthesia or IV sedation request

Denial Risk

Denial for convenience or lack of need

Requests may be denied when sedation or general anesthesia is requested for convenience, when the member/enrollee is cooperative with minimal dental needs, or when there is documented history of tolerating similar procedures without the need for sedation.

Documentation Required

Qualified anesthesia provider and monitoring requirements

Sedation must be administered by a qualified anesthesia provider; the provider must be able to provide PALS-level pediatric resuscitation and rescue skills. A second PALS-certified observer must be present to assist during deep sedation or general anesthesia and to continuously monitor the patient, particularly for pediatric patients under age eight.

Qualified providers: medical anesthesiologist, certified registered nurse anesthetist (CRNA), dentist anesthesiologist, or a second oral surgeon

IV Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated stimulation; ability to maintain ventilatory function may be impaired and patients may require assistance to maintain a patent airway.

General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, often require assistance to maintain respiratory function and may need positive-pressure ventilation; cardiovascular function may be impaired.