Dental services requiring general anesthesia performed in a hospital setting
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Memorandum describing new prior authorization requirements and supporting forms for pediatric dental procedures performed under general anesthesia in a hospital setting for Hawaii Med-QUEST fee-for-service dental providers and FQHCs.
Effective January 1, 2021, four supporting documents must be submitted with prior authorization requests for pediatric dental services requiring general anesthesia performed in a hospital-based setting.
Prior authorization may be submitted via Request for dental authorization form, ADA claim form, or via HDSMedicaid.org.
A Points-based 'Criteria for Dental Therapy Under General Anesthesia' (DHS 1190) form with a 22-point threshold and behavioral/clinical point categories must be completed and signed by parent/guardian and dentist.
A General Anesthesia Preauthorization Request Case Details/Checklist (DHS 1191) is required to confirm attached documents and alternatives attempted; incomplete documentation will result in denial.
A Parental General Anesthesia Risk Acknowledgment form (DHS 1192) requiring parent/guardian signature acknowledging risks and alternatives is required.
Coverage Criteria for General Anesthesia (GA)
Criteria for consideration of GA
Consideration for dental therapy under general anesthesia is granted only when ALL of the following are provided and the scoring criteria are met:
Incomplete submissions are subject to denial.
Scoring components include age, number of teeth/sextants, behavior rating, and additional factors; behavior and additional factors must be supported by narrative/documentation.
Select one age category on DHS 1190.
Select one extent category on DHS 1190.
Behavior rating entries on DHS 1190 must be supported in submitted narrative/case notes.
Each applicable additional factor must be supported by narrative/documentation.
Examples: definitely negative behavior scores, presence of pathology requiring surgical intervention, failed conscious sedation, medically compromising condition.
If alternatives are not documented, request may be denied.
Form DHS 1192 is required with the preauthorization submission.
DHS 1190 page includes performing dentist signature block; omission may lead to denial.
General anesthesia (GA) for pediatric dental treatment is reserved for patients who cannot be safely or effectively treated in a dental office because of serious medical or behavioral issues. The parental acknowledgement form (DHS 1192) states that hospital-based GA "is considered appropriate only for patients with serious medical or behavior issues that don't allow treatment in a dentist's office," and that this setting is not a routine part of dental care. Providers should therefore request GA only when the patient’s medical condition or behavior precludes completion of necessary dental therapy in an office setting and when alternatives have been considered.
General anesthesia must not be used routinely for dental care. The parental acknowledgement (DHS 1192) makes clear that hospital-based GA "is not a normal part of fixing teeth" and is appropriate only when serious medical or behavioral justification exists. Requests for GA that lack documentation of a qualifying medical or behavioral condition, or that do not include the required supporting forms and checklist, will not meet the policy’s intent.
The preauthorization checklist (DHS 1191) requires explicit documentation of alternatives attempted (for example, psychological behavior management, protective physical restraint, nitrous oxide or light/moderate sedation, or treatment with SDF/IRT). Failure to document these alternatives and to attach the completed DHS forms may result in denial of the request.
Coding and Scoring Thresholds
Provider Responsibilities and Submission Requirements
Preauthorization required and accepted submission methods
Prior authorization is required for pediatric dental procedures under general anesthesia and must list the proposed procedures in the treatment plan. Submissions are accepted via: (a) the Request for dental authorization form; (b) the ADA Claim form; or (c) preauthorization submission via HDSMedicaid.org portal.
- Include the proposed procedures in the treatment plan with the PA request.
- Accepted submission methods: Request for dental authorization form; ADA Claim form; HDSMedicaid.org portal.
Complete DHS 1190 CDTUA scoring and obtain signatures
Complete the Criteria for Dental Therapy Under General Anesthesia (DHS 1190) and calculate the Total Points. The summed Total Points must meet the required threshold of 22 for the request to be considered, and the form must be signed by the parent/guardian and the performing dentist.
- Total points needed to justify consideration = 22.
- DHS 1190 includes age, number of teeth/sextants, behavior, and additional factors; behavior and additional factors must be supported in submitted narrative/documentation.
- Parent/guardian and performing dentist signatures are required on DHS 1190.
Document alternatives attempted on DHS 1191 checklist
Document all alternatives attempted prior to requesting general anesthesia on the General Anesthesia Preauthorization Request Case Details/Checklist (DHS 1191).
- Checklist requires indicating whether psychological behavior management was attempted.
- Checklist requires indicating whether protective physical restraint was attempted.
- Checklist requires indicating whether pharmacological alternatives (nitrous oxide or light/moderate sedation) were attempted.
- Checklist requires indicating whether treatment with SDF or interim restorations (IRT) was attempted.
Required forms and attachments for prior authorization
Include all required forms and supporting attachments with the prior authorization request: DHS 1190 (Criteria for Dental Therapy Under General Anesthesia), DHS 1191 (General Anesthesia Preauthorization Request Case Details/Checklist), DHS 1192 (Parental General Anesthesia Acknowledgement), the Request for dental authorization/ADA claim form or HDSMedicaid portal submission, plus case notes, tooth-specific diagnoses, and the treatment plan.
- Attach DHS 1190, DHS 1191, and DHS 1192 forms with signatures as applicable.
- Attach tooth-specific clinical diagnosis, intended treatment plan, and supporting case notes or narrative documentation.
- Submit via the accepted submission method (Request for dental authorization, ADA Claim form, or HDSMedicaid.org).
Denial risk for incomplete or missing documentation
Incomplete documentation or failure to include the required forms and supporting information with the prior authorization request will result in denial.
- Ensure DHS 1190, DHS 1191, DHS 1192, tooth-specific diagnoses, treatment plan, and case notes are all attached and complete.
- Use the DHS 1191 checklist to confirm all required documents and alternatives attempted are documented; missing or incomplete items may cause denial.
Background
Background: This policy reserves hospital-based general anesthesia for pediatric patients whose medical condition or behavior prevents safe, effective treatment in a dentist’s office. The DHS forms emphasize informed discussion of risks and alternatives; parents must acknowledge potential serious risks and providers must document behavior and prior alternatives on the checklist (DHS 1191) before GA will be considered.
Definitions
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