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    v1.0.31
    OpenPayerPolicy UpdatesAnesthesiologyProvidence Dental Anesthesia Coverage | OpenPayer
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    CurrentProvidence Health PlanPolicy 65

    Dental Anesthesia Services

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    This policy governs when dental anesthesia delivered in an ambulatory surgical center or hospital facility may be covered under the medical benefit for commercial and Medicare members. It applies to rare circumstances involving complicated medical conditions or situations in which anesthesia is unsafe or cannot be performed in a dental office.

    Policy Summary
    PayerProvidence Health Plan
    PolicyDental Anesthesia Services
    Policy CodePolicy N/A
    Change TypeAnnual review — no material changes
    Effective DateOctober 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSeptember 1, 2027
    Key ActionDocument the patient's complicated medical condition and establish why anesthesia is unsafe or cannot be performed in a dental office.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Required medical-necessity criteria
    2Listed billing codes
    Under 7Pediatric age example
    2Applicable plan products

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    No changesPolicy revision status

    Facility-Based Dental Anesthesia Coverage

    Facility-based dental anesthesia medical necessity

    Dental anesthesia services at an ambulatory surgical center or hospital facility may be considered medically necessary when both criteria are met:

    Both criteria required

    • A. Complicated medical condition: Documentation indicates that the patient has a complicated medical condition that indicates routine dental anesthesia.

      Examples may include multiple pulpally involved and abscessed teeth with complicating medical disease; emotionally unstable, uncooperative, or combative patients when treatment is extensive and impossible to accomplish in the office; blood dyscrasias such as leukemia or hemophilia requiring transfusions and close postoperative observation; allergies to local anesthesia in patients requiring extensive treatment; or a healthy child under 7 years of age when a physician documents necessity related to the extent of the procedures and lack of patient cooperation.

    • B. Dental-office anesthesia is not feasible: Anesthesia is either unsafe in a dental office or cannot be performed in a dental office.

    Dental anesthesia performed in a dental office is outside the scope of this policy. Review those services under the member's dental benefit rather than the medical benefit.

    Facility-based dental anesthesia is not medically necessary when documentation does not establish both a complicated medical condition indicating the need for routine dental anesthesia and that anesthesia is unsafe or cannot be performed in a dental office.

    Applicable Billing Codes

    CPTCPT
    41899Unlisted procedure, dentoalveolar structures
    HCPCSHCPCS
    G0330Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room
    Pediatric age example
    Age thresholdUnder 7 years of age
    Documentation requirementA physician must document the necessity for facility-based anesthesia.
    Documented rationaleThe necessity must relate to the extent of the dental procedures and the lack of patient cooperation.

    Documentation, Authorization, and Denial Risks

    Prior Authorization

    Request prior authorization for potentially covered unlisted services

    For potentially covered services addressed by this policy, prior authorization is recommended when submitting an unlisted code to avoid post-service denial. All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level.

    Documentation Required

    Document medical necessity and facility setting

    Document the patient's complicated medical condition and explain why routine dental anesthesia is indicated. Documentation must also establish that anesthesia is unsafe or cannot be performed in a dental office.

    Documentation Required

    Obtain physician documentation for young children

    Policy Background

    Facility-based outpatient dental anesthesia may be covered under the medical benefit in rare circumstances for children and adults with complicating medical conditions or circumstances that cannot be managed safely or effectively in a dental office. Examples include extensive treatment for uncooperative or combative patients, blood dyscrasias requiring transfusions and close postoperative observation, allergies to local anesthetics requiring extensive treatment, and extensive dental treatment for healthy children under 7 years of age when a physician documents the necessity based on the extent of the procedures and lack of patient cooperation.

    Definitions

    Deep sedation/general anesthesia
    AbbreviationDS/GA
    MeaningDeep sedation/general anesthesia
    Pediatric dental useAdministration of DS/GA by a well-trained certified licensed anesthesia provider is an accepted treatment modality for pediatric dental patients.
    Certified licensed anesthesia provider
    RoleCertified licensed anesthesia provider who administers deep sedation/general anesthesia and is independent of performing or assisting with the dental procedure.
    Physician or dentist anesthesiologistA physician anesthesiologist or dentist anesthesiologist may serve as the CLA, as permitted by state regulation.
    Policy Summary
    PayerProvidence Health Plan
    PolicyDental Anesthesia Services
    Policy CodePolicy N/A
    Change TypeAnnual review — no material changes
    Effective DateOctober 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSeptember 1, 2027
    Key ActionDocument the patient's complicated medical condition and establish why anesthesia is unsafe or cannot be performed in a dental office.
    SourceLink
    On This Page
    Facility-Based Dental Anesthesia CoverageApplicable Billing CodesDocumentation, Authorization, and Denial RisksPolicy BackgroundDefinitions

    For a healthy child under 7 years of age, physician documentation must establish necessity related to the extent of the dental procedures and lack of patient cooperation.

    Denial Risk

    Meet both medical-necessity criteria

    Facility-based dental anesthesia is not medically necessary unless documentation establishes both a complicated medical condition indicating that routine dental anesthesia is required and that anesthesia is unsafe or cannot be performed in a dental office.

    Note

    Submit dental-office anesthesia under the dental benefit

    Dental anesthesia performed in a dental office is reviewed under the member's dental benefit rather than this medical policy.

    Denial Risk

    Unlisted codes for non-covered services will be denied

    An unlisted code submitted for a non-covered service addressed by this policy will be denied as not covered.

    Nurse anesthetist
    A certified registered nurse anesthetist may serve as the CLA, as permitted by state regulation.
    Oral and maxillofacial surgeonAn oral and maxillofacial surgeon may serve as the CLA, as permitted by state regulation.