Dental Services Requiring General Anesthesia Performed in a Hospital Setting
Customize your policy alerts
Sign up for all Hawaii Department of Human Services policy alerts
Know when Hawaii Department of Human Services releases new policies or updates existing guidance.
Monitor payer policy activity
Memorandum outlining new prior authorization documentation and process for pediatric dental procedures requiring general anesthesia performed in hospital-based settings for Hawaii Med-QUEST fee-for-service dental providers and FQHCs.
Effective January 1, 2021, four supporting documents must be submitted with prior authorization for pediatric dental services requiring general anesthesia in a hospital setting.
Preauthorization may be submitted via three methods: existing Request for Dental Authorization form, ADA claim form, or through HDSMedicaid.org.
New specific forms (DHS 1190, DHS 1191, DHS 1192) are required: Criteria for Dental Therapy Under General Anesthesia, General Anesthesia Preauthorization Request Case/Details Checklist, and Parental General Anesthesia Acknowledgement.
Coverage criteria for general anesthesia (GA)
Criteria for consideration of GA (DHS 1190)
Consideration for dental treatment under general anesthesia is based on meeting a total points threshold on the Criteria for Dental Therapy Under General Anesthesia (DHS 1190) and providing the required supporting documentation.
GA authorization prerequisites
- Age points: Select the single applicable age category and record its points on DHS 1190: Less than 4 years = 8; 4–5 years = 6; 6–7 years = 4; 8 years and older = 2.see DHS 1190
You must select the single applicable age group.
- Extent of treatment points: Select the single bracket that matches number of teeth or sextants involved and record its points on DHS 1190: 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.see DHS 1190
Choose the matching bracket for number of teeth/sextants.
- Behavior points: Document behavior and assign points per DHS 1190: cautious acceptance/fearful behaviors = 0; somewhat negative/defiant behaviors = 4; definitely negative/hysterical or combative/unable to cooperate due to maturity or disability = 10.see DHS 1190
Behavior descriptions must be supported in the submitted narrative/documentation.
- Additional factors: Select all applicable additional factors on DHS 1190: presence of oral/perioral pathology/anomaly/trauma requiring surgical intervention; failed conscious sedation (nitrous oxide is not considered conscious sedation); medically compromising or handicapping condition. Record points as indicated on the form.points as indicated on form
Each selected additional factor must be supported in documentation.
- Total points and documentation: Total the points from all sections and document the total on DHS 1190. A total of 22 points or more is required to justify consideration of GA. Include DHS 1190 and all supporting documentation as part of the preauthorization request.Total points >= 22
To proceed, DHS 1190 and all supporting documentation detailed in the General Anesthesia Preauthorization Request Case Details/Checklist (DHS 1191) must be submitted with the preauthorization.
General anesthesia for pediatric dental procedures is reserved for patients with serious medical or behavioral conditions that prevent safe and effective treatment in the dentist’s office. The Parental General Anesthesia Acknowledgement (DHS 1192) explicitly states that hospital-based GA is not a routine part of dental care and should be considered only when other options are inadequate. Providers should ensure that families understand the inherent risks described on the acknowledgement form before proceeding.
The General Anesthesia Preauthorization Case Details/Checklist (DHS 1191) and the Parental General Anesthesia Acknowledgement (DHS 1192) are required parts of the authorization packet and document context for use of GA. DHS 1191 includes a checklist to confirm attached supporting documents and asks providers to document what alternative modalities were attempted. DHS 1192 records that the parent/guardian was informed of risks, alternatives, and that hospital GA is considered appropriate only for patients with serious medical or behavior issues that preclude office-based care.
Coding and scoring thresholds
Prior authorization and documentation requirements for providers
Submit prior authorization with proposed treatment and accepted submission method
Prior authorization is required for pediatric dental services requiring general anesthesia and the submission must include the procedures proposed in the treatment plan. Prior authorization requests may be submitted using the Request for Dental Authorization form, the ADA Claim form, or via the HDSMedicaid.org portal.
Document alternatives attempted on DHS 1191 checklist
Document all alternative, less-invasive treatment modalities attempted prior to requesting general anesthesia using the Case Details/Checklist (DHS 1191). The checklist specifically requires indicating whether psychological behavior management, protective physical restraint, pharmacological alternatives (nitrous oxide or light/moderate sedation), or treatments such as SDF/IRT were tried.
- Psychological behavior management
- Protective physical restraint
- Pharmacological alternatives (nitrous oxide or light/moderate sedation)
- Treatment with SDF or IRT
Attach DHS 1190, DHS 1191, DHS 1192 and supporting case notes
Include the completed preauthorization packet with the prior authorization: the Criteria for Dental Therapy Under General Anesthesia (DHS 1190), the General Anesthesia Preauthorization Request Case/Details Checklist (DHS 1191), and the Parental General Anesthesia Acknowledgement (DHS 1192), plus the proposed tooth-specific clinical diagnosis, intended treatment plan, and patient case notes/chart as indicated.
- DHS 1190 — Criteria for Dental Therapy Under General Anesthesia (signed by parent/guardian and dentist; may include case notes/chart)
- DHS 1191 — General Anesthesia Preauthorization Request Case/Details Checklist (attach tooth-specific diagnosis and treatment plan; checklist items and supporting details)
- DHS 1192 — Parental General Anesthesia Acknowledgement (parent/guardian review and signature)
- Proposed procedures in the treatment plan and tooth-specific clinical diagnosis
- Attach patient case notes and/or chart documentation as indicated
Denial risk for incomplete or missing documentation
Incomplete documentation or failure to include the required DHS forms and written case notes/supporting information will result in a denial of the prior authorization request.
Background and policy scope
The memorandum frames the rationale for hospital-based general anesthesia around patient safety and necessity: GA is intended for children whose medical condition or behavior prevents completion of needed dental care in the office. The parental acknowledgement emphasizes that GA carries potential serious risks (for example, vomiting, breathing or heart problems, allergic reactions, brain damage, or death) and that less invasive alternatives — including delaying treatment, behavioral coaching, protective holding, nitrous oxide, minimal sedation, or interim/restorative measures — should be discussed and documented prior to electing GA.
Definitions and form identifiers
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.