CurrentSelectHealthPolicy DOO8

Dental Anesthesia Coverage (D008)

Defines SelectHealth coverage policy for dental anesthesia (local, conscious sedation, deep sedation, general anesthesia, IV sedation) for commercial and SelectHealth Advantage plans, including indications when anesthesia is considered dentally necessary, age limits for non-IV conscious sedation, coverage limits, provider certification requirements, and applicable CDT billing codes.

Policy Summary

PayerSelectHealth

PolicyDental Anesthesia Coverage (D008)

Policy CodePolicy DOO8

Change TypeRevision history (no material clinical changes)

Effective DateJan 1, 2009

Next Review DateN/A

Key ActionAdditional anesthesia charges beyond 1 hour 15 minutes require review and must be supported by documentation demonstrating extreme complexity or a large number of procedures.

SourceLink

POLICY UPDATE CHANGES

Revision date listed as 01/05/23; review dates include 07/28/22 and 01/05/2023.

7Listed dentally necessary procedure types

6Allowed non-IV conscious sedation pediatric age threshold

75Standard anesthesia time allowance

Coverage Summary

Scope: Defines SelectHealth coverage policy for dental anesthesia including local anesthesia, conscious sedation, deep sedation, general anesthesia, and IV sedation for both commercial and SelectHealth Advantage (Medicare/CMS) plans. Policy outlines indications when anesthesia is considered dentally necessary, age limits for non-IV conscious sedation, coverage time limits, provider certification requirements, and applicable CDT billing codes. SelectHealth Advantage follows the commercial plan.

Coverage stance: mixed. Status: CURRENT. Effective date: 2009-01-01. Last review: 2023-01-05.

Key thresholds and quick facts

Anesthesia time allowance1 hour 15 minutes

Allowed non-IV conscious sedation pediatric age thresholdAges 6 and under

Number of listed dentally necessary procedure types7

Medical Necessity / Coverage Criteria

General coverage rules

General anesthesia and IV sedation are covered when ALL of the following are met:

ALL of the following

General anesthesia/IV sedation type: The anesthesia is general anesthesia or IV sedation provided as an in-office adjunctive procedure
Related procedure coverage: The related dental procedure is a covered benefit under the member's plan
Provider certification: The provider has appropriate state certification to perform general anesthesia/IV sedation (see Dentist and Dental Hygienist Practice Act Rules R156-69-201 and 202) and has necessary insurance coverage

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title

General coverage rules

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Specific covered dental procedures (when general anesthesia or IV sedation is dentally necessary)

General anesthesia and IV sedation are considered dentally necessary and covered when provided as an in-office adjunctive procedure for ANY of the following:

ANY of the following

Impacted teeth: Removal of completely and partially bony impacted teeth.
Multiple extractions: Surgical extraction of three or more teeth performed on the same day.
Alveoloplasty: Full edentulous arch alveoloplasty or alveolectomy.
Implant placement: Placement of one or more implants.

Non-IV conscious sedation

Non-intravenous conscious sedation coverage conditions:

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Non-IV conscious sedation

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Time/charge limits

Coverage time limit and additional charges:

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Time/charge limits

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Local anesthesia

Local anesthesia coverage rule:

Local anesthesia inclusive: Local anesthesia is considered inclusive to operative or surgical procedures (i.e., not separately payable when provided with those procedures).

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Local anesthesia

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Therapeutic parenteral drugs

Drug charge inclusion:

Therapeutic parenteral drugs inclusive: Charges for therapeutic parenteral drugs are considered inclusive with anesthesia charges.

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Therapeutic parenteral drugs

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Coding

Anesthesia and sedation CDT codes (listed for informational/billing purposes)mixed

D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia
D9222	Deep sedation/general anesthesia - first 15 minutes
D9223	Deep sedation/general anesthesia - each subsequent 15 minute increment
D9239	Intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation
D9610	Therapeutic parenteral single administration drug
D9612	Therapeutic parenteral drugs, two or more administrations, different medications

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Provider Actions & Billing Rules

Prior Authorization

Additional anesthesia time requires review

Additional anesthesia charges beyond 1 hour 15 minutes require review to determine dental necessity and must be supported by documentation demonstrating extreme complexity or a large number of procedures.

Documentation Required

Provider certification and insurance

Provider must have appropriate state certification to perform general anesthesia/IV sedation per the Dentist and Dental Hygienist Practice Act Rules R156-69-201 and 202, and must have necessary insurance coverage; documentation should be available to demonstrate certification and insurance.

Billing Rule

Local anesthesia inclusive

Local anesthesia (D9210) is considered inclusive to operative or surgical procedures and should not be billed separately when provided with those procedures.

D9210

Billing Rule

Therapeutic parenteral drugs inclusive

Charges for therapeutic parenteral drugs are considered inclusive with anesthesia charges and are not separately payable.

D9610
D9612
D9613

Background & Definitions

Background: The policy defines anesthesia levels: Local Anesthesia as elimination of sensation by topical or regional drug application; Conscious Sedation as a minimally depressed level of consciousness with retained airway and response to stimulation/command; Deep Sedation as depressed consciousness with partial loss of protective reflexes and inability to continuously maintain airway or respond purposefully; and General Anesthesia as induced unconsciousness with partial or complete loss of protective reflexes and inability to maintain airway independently or respond purposefully.

Coverage conditions: Anesthesia coverage requires that the underlying dental procedure be a covered benefit under the member’s plan and that the provider have appropriate state certification and necessary insurance to perform general anesthesia/IV sedation (per Dentist and Dental Hygienist Practice Act Rules R156-69-201 and 202). SelectHealth Advantage will follow the commercial plan.

Term	Definition
Local Anesthesia	The elimination of sensation, especially pain, in one part of the body by topical application or regional injection of a drug.
Conscious Sedation	A minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or non-pharmacological method or a combination thereof.
Deep Sedation	An induced state of depressed consciousness accompanied by partial loss of protective reflexes, including the inability to continually maintain an airway and respond purposefully to physical stimulation or verbal command, produced by pharmacologic or non-pharmacologic methods or a combination thereof.
General Anesthesia	An induced state of unconsciousness, accompanied by a partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently and respond purposefully to physical stimulation or verbal command, produced by pharmacologic or non-pharmacologic methods or a combination thereof.

Revision History

01/05/23revision

Revision date listed as 01/05/23; document shows revision history but does not state clinical policy changes.

07/28/22review

Review date listed as 07/28/22; document shows revision history but does not state clinical policy changes.

01/05/2023review

Review date listed as 01/05/2023; document shows revision history but does not state clinical policy changes.

Policy Summary

PayerSelectHealth

PolicyDental Anesthesia Coverage (D008)

Policy CodePolicy DOO8

Change TypeRevision history (no material clinical changes)

Effective DateJan 1, 2009

Next Review DateN/A

Key ActionAdditional anesthesia charges beyond 1 hour 15 minutes require review and must be supported by documentation demonstrating extreme complexity or a large number of procedures.

SourceLink

On This Page

Surgical exposure of bony impacted or unerupted cuspids (e.g., impacted bicuspid or canine teeth).

Periodontal surgery: One or more quadrants of periodontal (osseous) surgery performed on the same day.

Pediatric complexity

Pediatric - age: A child under years old
Missing exact age in policy text
Pediatric - condition complexity: Dental condition of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions or combinations of these or other dental procedures).

Specific covered dental procedures (when general anesthesia or IV sedation is dentally necessary)

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title": "Local anesthesia"