CurrentKaiser PermanentePolicy 00-00

general_anesthesia_for_dental_procedures_policy

Defines coverage for general anesthesia and facility charges for dental procedures when medically necessary under specified member conditions and subject to prior authorization and designated facility requirements. Dental procedure fees themselves are excluded.

Policy Summary

PayerKaiser Permanente

Policygeneral_anesthesia_for_dental_procedures_policy

Policy CodePolicy 00-00

Change TypeReviewed/Revised

Effective DateFeb 13, 2023

Next Review Date

Key ActionQuality Resource Management must authorize general anesthesia services in advance; ensure services occur in a Health Plan–designated hospital or ambulatory surgical facility and bill only anesthesia and facility fees (dental procedure fees are not covered).

SourceLink

POLICY UPDATE CHANGES

No material changes

4Covered clinical indications (age/developmental/medical/trauma)

Coverage Summary

This policy covers general anesthesia and associated facility charges for dental procedures when medically necessary per Georgia state law and internal Utilization Management requirements. Coverage stance: covered_with_criteria.

Coverage is limited to the anesthesia fee and facility fees; dental professional/procedure fees are excluded and are not a covered benefit.

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Coverage Criteria for General Anesthesia and Facility Charges

Covered when ALL of the following are met:

ALL of the following

Member is age 7 years or younger
Member is developmentally disabled
Member is unable to receive dental care under local anesthesia due to a neurological or medically compromising condition
Member has sustained extensive facial or dental trauma
Quality Resource Management (QRM) must authorize services in advance
Prior authorization required
Member must receive services in a Hospital or ambulatory surgical facility that the Health Plan designates
Designated facility requirement
Coverage is limited to the anesthesia fee and the facility fees; dental procedure fees are not covered

Provider Actions / Requirements

Prior Authorization

Prior authorization required

Quality Resource Management must authorize general anesthesia services in advance.

Documentation Required

Designated facility requirement

Services must be provided in a Hospital or ambulatory surgical facility designated by the Health Plan.

Billing Rule

Limit on covered fees

Coverage is limited to anesthesia and facility fees; dental procedure fees are not a covered benefit and should not be billed as covered under this policy.

Definitions & Background

This policy defines the scope of coverage for general anesthesia services for dental procedures. The Health Plan will cover associated general anesthesia and facility charges if the Member meets specified clinical criteria and the services are authorized in advance and provided in a designated facility. Dental professional fees are explicitly excluded from coverage.

Definition: Quality Resource Management (QRM) — Utilization management entity responsible for prior authorization of services.

Quality Resource Management (QRM) — Utilization management entity responsible for prior authorization of services.