CurrentTexas Children's Health PlanPolicy 8432

General Anesthesia for Dental Procedures in Members 6 years old and Younger

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Prior authorization and medical-necessity review for general anesthesia and associated facility fees during dental procedures for Texas Children's Health Plan members enrolled in STAR or STAR Kids.

Policy Summary

PayerTexas Children's Health Plan

PolicyGeneral Anesthesia for Dental Procedures in Members 6 years old and Younger

Policy CodePolicy 8432

Change TypeNo material change

Effective DateOct 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization before providing general anesthesia and the associated facility fee for dental procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤6 yearsPrimary member population

22 pointsMinimum criteria score

00170Anesthesia code

G0330Facility fee code

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CurrentTexas Children's Health PlanPolicy 8432

General Anesthesia for Dental Procedures in Members 6 years old and Younger

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 8432 alerts

Get alerted when Policy 8432 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Prior authorization and medical-necessity review for general anesthesia and associated facility fees during dental procedures for Texas Children's Health Plan members enrolled in STAR or STAR Kids.

Policy Summary

PayerTexas Children's Health Plan

PolicyGeneral Anesthesia for Dental Procedures in Members 6 years old and Younger

Policy CodePolicy 8432

Change TypeNo material change

Effective DateOct 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization before providing general anesthesia and the associated facility fee for dental procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤6 yearsPrimary member population

22 pointsMinimum criteria score

00170Anesthesia code

G0330Facility fee code

Medical Necessity Criteria

Medical necessity for general anesthesia during dental procedures

General anesthesia during dental services is considered medically necessary when the required authorization documentation is submitted and at least one of the following clinical criteria is met.

Required authorization documentation: The request includes the location where the procedure will be performed, a narrative explaining the reason for the proposed level of anesthesia, proof of authorization for the dental services from the dental maintenance organization (DMO) for STAR or STAR Kids members, a completed Criteria for Dental Therapy Under General Anesthesia form showing at least 22 total points, and diagnostic-quality radiographs or photographs unless the narrative documents why they could not be obtained before anesthesia.at least 22 total points

These documentation requirements apply to the request; the clinical indications below are alternatives.

Clinical indications — ONE of

Failed or contraindicated conscious sedation: The child is up to 20 years of age and in-office conscious sedation has failed or is clinically contraindicated.
Medical compromise requiring enhanced safety resources: The patient is medically compromised and the medical history indicates that monitoring of vital signs or availability of resuscitative equipment is necessary during dental procedures.
Extensive procedures with medical conditions precluding office sedation: The patient requires extensive dental procedures and has uncontrolled bleeding, severe cerebral palsy, or another medical condition that renders conscious sedation in the office medically inappropriate.
Behavioral or psychiatric condition: The patient requires extensive dental procedures and has documentation of a significant behavioral health condition or psychiatric disorder requiring special treatment, such as severe panic disorder.
Cognitive disability: The cognitively disabled patient requires extensive procedures and the prior history indicates that general anesthesia is appropriate.
Cleft lip or palate repair: The child requires repair of a cleft lip or palate.

Additional review for members ages 7 through 20

For members ages 7 through 20, TCHP reviews medical necessity when either of the following conditions applies.

Additional review conditions — ONE of

Below threshold: The member does not meet the 22-point threshold.less than 22 points
Repeated anesthesia: The member needs general anesthesia more than once per 6 months.more than once per 6 months

Authorization Codes and Frequency Rules

Codes requiring prior authorizationmixed

00170	General anesthesia
G0330	Facility fee

Criteria for Dental Therapy Under General Anesthesia

Criteria formCriteria for Dental Therapy Under General Anesthesia

Minimum required scoreAt least 22 total points

Documentation useThe completed form must show at least 22 total points for prior authorization

General anesthesia frequency for members ages 7 through 20

Applicable membersMembers ages 7 through 20

Frequency thresholdMore than once per 6 months

Required action

Authorization and Documentation Requirements

Prior Authorization

Advance Authorization Required

Advance authorization is required for general anesthesia during dental procedures and the associated facility fee for STAR and STAR Kids members. Authorization applies to the anesthesia and facility components of the medical benefit; dental services remain the responsibility of the member’s dental maintenance organization (DMO).

General anesthesia: CPT 00170
Facility fee: HCPCS G0330
Submit requests to Utilization Management by fax, mail, or electronic submission during normal business hours.

Note

Failed or Contraindicated Conscious Sedation

General anesthesia may be medically necessary for children up to age 20 when in-office conscious sedation has failed or is clinically contraindicated.

The request must explain the failed or contraindicated conscious sedation and why the proposed anesthesia level is appropriate.

Policy Scope and Clinical Context

This guideline explains when general anesthesia may be medically necessary to facilitate dental procedures when office-based conscious sedation is unsuccessful, clinically contraindicated, or otherwise medically inappropriate. It addresses anesthesia and associated facility components of the medical benefit for eligible Texas Children's Health Plan members, while the dental provider remains responsible for dental services authorized through the member’s dental maintenance organization.

Policy Summary

PayerTexas Children's Health Plan

PolicyGeneral Anesthesia for Dental Procedures in Members 6 years old and Younger

Policy CodePolicy 8432

Change TypeNo material change

Effective DateOct 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization before providing general anesthesia and the associated facility fee for dental procedures.

SourceLink

On This Page

Medical-necessity review by TCHP

Unsupported block type: documentation

Billing Rule

Modifiers and Medicaid Billing Requirements

Use appropriate modifiers for general anesthesia and facility-fee claims in accordance with the current Texas Medicaid Provider Procedure Manual at the time of the request.

Apply current Texas Medicaid billing requirements and modifiers to the applicable services.

Denial Risk

Less Than 22 Criteria Points

Requests may not be supported when the completed Criteria for Dental Therapy Under General Anesthesia form documents fewer than the required 22 total points.

The completed form must show at least 22 total points for standard documentation support.
TCHP reviews medical necessity for members ages 7 through 20 who do not meet the 22-point threshold.

Denial Risk

Incomplete Documentation

Missing required documentation may prevent Utilization Management from determining that the request is an eligible service and may result in denial or referral for physician review.

Required materials include the procedure location, anesthesia-level rationale, DMO authorization when applicable, the completed criteria form, and diagnostic-quality radiographs or photographs or an explanation of why they could not be obtained.

Note

Age or Frequency Exception Review

TCHP reviews medical necessity for general anesthesia requests for members ages 7 through 20 when the request falls below the 22-point threshold or when general anesthesia is requested more than once per six months.

Age exception review: members ages 7 through 20
Frequency exception review: more than once per 6 months

Denial Risk

Failure to Meet Medical Necessity

Requests that do not meet the medical-necessity criteria established by the guideline will be referred to a TCHP Medical Director or physician reviewer for review.

Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility.

Prior Authorization

No Advance Authorization or Benefit Limitation

Obtain advance authorization for general anesthesia and the associated facility fee before dental-related anesthesia services. Approval addresses medical necessity only; all services remain subject to applicable benefit limitations and exclusions.

Failure to comply with state and federal regulatory requirements may result in retrospective audit and potential financial recoupment.
Authorization for treatment or a particular service does not guarantee benefits or eligibility.