general_anesthesia_for_dental_procedures_policy
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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.
No material changes
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.
Coverage Criteria for General Anesthesia and Facility Charges
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 required
Quality Resource Management must authorize general anesthesia services in advance.
Designated facility requirement
Services must be provided in a Hospital or ambulatory surgical facility designated by the Health Plan.
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.
Revision History
Policy effective
Last review
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