Dental Services Requiring General Anesthesia Performed in a Hospital Setting
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Memorandum describing new prior authorization requirements and required supporting forms for pediatric dental procedures performed with general anesthesia in a hospital setting for Hawaii Medicaid fee-for-service and FQHC dental providers.
Effective January 1, 2021, four supporting documents must be submitted with prior authorization requests for pediatric dental services requiring general anesthesia in a hospital setting.
Preauthorization may be submitted via Request for dental authorization form, ADA Claim form, or the HDSMedicaid.org portal.
Required supporting documents now include a signed Criteria for Dental Therapy Under Anesthesia form, a Parental General Anesthesia Risk Acknowledgment form, and a General Anesthesia Preauthorization Request Case/Details Checklist.
Coverage Criteria for General Anesthesia
Criteria for consideration of GA
Consideration for dental therapy under general anesthesia is allowed when the Criteria for Dental Therapy Under General Anesthesia and required supporting documentation meet the stated requirements.
Overall requirement
Points-based justification
- Age points: Select one age tier and assign corresponding points
Less than 4 yrs = 8; 4–5 yrs = 6; 6–7 yrs = 4; 8+ yrs = 2
- Extent of treatment (teeth/sextants): Select one extent tier and assign corresponding points
1–2 teeth or 1 sextant = 3; 3–4 teeth or 2–3 sextants = 6; 5–8 teeth or 4 sextants = 9; 9+ teeth or 5–6 sextants = 12
- Behavior: Select the behavior level supported by submitted narrative/documentation and assign corresponding points
Behaviors such as fearful/crying/nervous/cautious acceptance = 0; somewhat negative/defiant/restless/refusal of radiographs = 4; definitely negative/hysterical/combative/unable to cooperate = 10
- Additional factors: Select all applicable additional factors and add their points
Presence of oral/perioral pathology requiring surgical intervention; failed conscious sedation (nitrous oxide not considered conscious sedation); medically compromising or handicapping condition (each factor is scored as indicated on DHS 1190)
- Documentation requirements: Submit signed DHS 1190 (Criteria for Dental Therapy Under General Anesthesia), DHS 1191 (Preauthorization Case Details/Checklist), DHS 1192 (Parental General Anesthesia Acknowledgement), tooth-specific clinical diagnosis and treatment plan, and case notes as evidence
Incomplete documentation or missing required forms may result in denial; checklist must document attempted alternatives to GA when behavior is the reason
Performing dentist must sign DHS 1190; form DHS 1190 is DHS 1190 (01/2021)
General anesthesia (GA) for pediatric dental treatment is reserved for patients with serious medical or behavioral limitations that prevent safe or effective care in a dentist's office. The policy requires that GA be justified using the Criteria for Dental Therapy Under General Anesthesia (DHS 1190), which assigns points for factors such as age, extent of treatment, behavior severity, and additional clinical considerations. Prior authorization must be obtained and accompanied by the required supporting documents (signed DHS 1190, DHS 1191 checklist, DHS 1192 parental acknowledgement, treatment plan and case notes) to document the medical/behavioral rationale for GA.
GA is not appropriate for routine dental visits and is explicitly described in the parental acknowledgement as "not a normal part of fixing teeth." It should be reserved for cases where in‑office management is not possible due to significant medical compromise or behavior that cannot be managed with less invasive alternatives. Providers and families should consider and document other options (for example: delaying treatment, restraint techniques, nitrous oxide, minimal sedation, behavioral coaching, or interim/medicinal approaches) before proceeding with hospital‑based GA.
Submission Methods, Scoring, and Form Identifiers
| Request for dental authorization form | Request for dental authorization form (existing) |
| ADA Claim form | ADA Claim form (new) |
| HDSMedicaid.org portal | Preauthorization submission via HDSMedicaid.org (new) |
Prior Authorization, Required Documentation, and Denial Risk
Prior authorization must include proposed procedures and may be submitted via three methods
Prior authorization is required for pediatric dental services performed with general anesthesia in a hospital setting and the submission must include the procedures proposed in the treatment plan. Requests may be submitted using any of the three methods: Request for dental authorization form, ADA Claim form, or via the HDSMedicaid.org portal (https://www.hdsmedicaid.org).
- Include the procedures proposed in the treatment plan with the prior authorization request.
- Submission methods: Request for dental authorization form; ADA Claim form; HDSMedicaid.org portal.
Document attempts at alternative treatments on the GA checklist when behavior is the reason
When behavior is the reason for requesting general anesthesia, the provider must document attempts at alternative treatment modalities on the General Anesthesia Preauthorization Request Case/Details Checklist.
- Document attempted psychological behavior management.
- Document attempted protective physical restraint.
- Document pharmacologic alternatives (e.g., nitrous oxide or light/moderate sedation).
- Document non‑operative options such as treatment with SDF or IRT.
- If behavior is the reason for GA, describe the patient behavior in detail on the checklist.
Include treatment plan plus DHS 1190, DHS 1191, DHS 1192, and case notes with preauthorization
Submit the treatment plan with proposed, tooth‑specific procedures plus the three named DHS forms and supporting case notes as required by the checklist: DHS 1190 (Criteria for Dental Therapy Under General Anesthesia), DHS 1191 (General Anesthesia Preauthorization Request Case/Details Checklist), and DHS 1192 (Parental General Anesthesia Acknowledgement). Include written case notes and any supporting documentation indicated on the checklist.
- Treatment plan with tooth‑specific clinical diagnosis and intended treatment plan (attached to request).
- Signed DHS 1190 — Criteria for Dental Therapy Under General Anesthesia.
- Completed DHS 1191 — General Anesthesia Preauthorization Request Case/Details/Checklist.
- Signed DHS 1192 — Parental General Anesthesia Acknowledgement.
- Written case notes and supporting documentation as indicated on the checklist.
Incomplete or missing checklist/forms may cause denial
Incomplete documentation on the General Anesthesia Preauthorization Request Case/Details Checklist or missing required forms will result in a denial of the prior authorization request.
- Ensure the checklist is complete and all required DHS forms (DHS 1190, DHS 1191, DHS 1192) are attached.
- Provide written case notes and any supporting information requested on the checklist to avoid denial.
Background
The underlying rationale for restricting GA to hospital settings is patient safety: GA renders a child unconscious and may require airway support and monitoring, and carries risks including vomiting, sore throat, respiratory or cardiac complications, allergic reaction, brain injury, or death. Because of these risks, GA is intended primarily for those with medical or behavioral conditions that make office‑based treatment unsafe or impossible, and families are asked to acknowledge these risks and that other less invasive options exist.
Definitions and Forms
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