CurrentUnitedHealthcarePolicy DCP016.19

General Anesthesia and Conscious Sedation Services

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This policy addresses nitrous oxide, non-intravenous sedation, intravenous moderate/conscious sedation, deep sedation, general anesthesia, and local anesthesia when provided in a dental office. Hospital operating room and ambulatory surgery center anesthesia services are governed by the member-specific benefit plan and applicable federal or state mandates.

Policy Summary

PayerUnitedHealthcare

PolicyGeneral Anesthesia and Conscious Sedation Services

Policy CodePolicy DCP016.19

Change TypeNo material clinical or coverage change

Effective DateSeptember 1, 2026

Next Review DateNot specified

Key ActionEnsure a designated individual other than the proceduralist monitors the patient throughout sedated procedures.

SourceLink

POLICY UPDATE CHANGES

Supporting information was updated in the Clinical Evidence and References sections to reflect current information.

16Applicable dental anesthesia and sedation procedure codes listed

6Sedation and anesthesia terms defined

5Absolute contraindications to nitrous oxide identified

ASA III+

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CurrentUnitedHealthcarePolicy DCP016.19

General Anesthesia and Conscious Sedation Services

Customize your policy alerts

Sign up for UnitedHealthcare Policy DCP016.19 alerts

Get alerted when Policy DCP016.19 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicyGeneral Anesthesia and Conscious Sedation Services

Policy CodePolicy DCP016.19

Change TypeNo material clinical or coverage change

Effective DateSeptember 1, 2026

Next Review DateNot specified

Key ActionEnsure a designated individual other than the proceduralist monitors the patient throughout sedated procedures.

SourceLink

POLICY UPDATE CHANGES

Supporting information was updated in the Clinical Evidence and References sections to reflect current information.

16Applicable dental anesthesia and sedation procedure codes listed

6Sedation and anesthesia terms defined

5Absolute contraindications to nitrous oxide identified

ASA III+

Higher-risk medical status identified for adverse events

1Clinical safety warning concerning nitrous oxide with intraocular gas

2Plan types addressed

Dental Anesthesia and Sedation Coverage Criteria

Nitrous Oxide Indications

Nitrous oxide may be indicated for any of the following situations.

Nitrous oxide indications

Extensive and/or complex procedures, such as serial extractions or periodontal surgeries.
Individual with a physical, cognitive, or developmental disability.
Local anesthesia is ineffective.
Management of a severe gag reflex.
Management of fear and anxiety.

Intravenous Moderate/Conscious Sedation and Deep Sedation/General Anesthesia Indications

Intravenous moderate/conscious sedation and deep sedation/general anesthesia, including advanced airway, may be indicated for any of the following situations.

Intravenous moderate/conscious sedation and deep sedation/general anesthesia indications

Allergy or sensitivity to local anesthetic agents.
Extensive and/or complex procedures, such as serial extractions or periodontal surgeries.
Anxiety and fear when other techniques have proven inadequate.
Behavioral management when other techniques have proven inadequate.
Individual is medically compromised or has special needs.

Non-Intravenous Sedation Indications

Non-intravenous sedation may be indicated for any of the following situations.

Non-intravenous sedation indications

Individual with a physical, cognitive, or developmental disability.
Mild to moderate apprehension and anxiety.

Nitrous oxide is absolutely contraindicated for patients with methylenetetrahydrofolate reductase (MTHFR) deficiency, pulmonary hypertension, severe chronic obstructive pulmonary disease (COPD), treatment with bleomycin sulfate, vitamin B12 deficiency, or within three months of vitreoretinal surgery.

Nitrous oxide may be contraindicated in patients with claustrophobia, pregnancy, severe underlying medical conditions such as critical illness or cardiac disease, significant personality or behavioral disorders, or upper respiratory tract infections and other respiratory conditions.

Any type of sedation or general anesthesia may be contraindicated when the patient has an increased risk of adverse outcomes or complications. Factors to consider include abnormalities of major organ systems, a previous adverse experience with sedation or analgesia, drug allergies, current medications and potential drug interactions, tobacco, alcohol, or substance use or abuse, and the time and nature of the patient's last oral intake.

Applicable Dental Anesthesia and Sedation Codes

Applicable CodesHCPCS

D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia
D9215	Local anesthesia in conjunction with operative or surgical procedures
D9219	Evaluation for moderate sedation, deep sedation or general anesthesia
D9222	Administration of deep sedation/general anesthesia - first 15 minute increment, or any portion thereof
D9223	Administration of deep sedation/general anesthesia - each subsequent 15 minute increment, or any portion thereof
D9224	Administration of general anesthesia with advanced airway - first 15 minute increment, or any portion thereof
D9225	Administration of general anesthesia with advanced airway - each subsequent 15 minute increment, or any portion thereof
D9230	Administration of nitrous oxide

1–10 of 16

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Monitoring, Documentation, and Office-Based Safety

Documentation Required

Sedation Monitoring and Documentation

Follow applicable state laws, rules, and regulations and meet the ADA’s education and training requirements for the level of sedation or anesthesia provided. Before and during care, complete and document the required patient evaluation, personnel and equipment readiness, monitoring, and recovery processes.

Document the patient history and evaluation.
Verify personnel qualifications and required equipment.
Monitor and document consciousness, oxygenation, ventilation, and circulation.
Document recovery and discharge and maintain emergency-management procedures.

Note

Office-Based Safety Requirements

Apply office-based safeguards based on patient risk, procedure duration and extent, and depth of sedation. Arrange appropriate medical evaluation or a more suitable facility when indicated, and maintain qualified monitoring, rescue capability, equipment, emergency drugs, and emergency-response protocols.

Clinical Background

Local anesthesia is common for routine dental procedures, but some patients may require different levels of dental sedation or anesthesia to safely receive care. Sedation and anesthesia are generally safe when administered by trained, certified providers in an appropriate setting, but they carry risks. Pediatric patients and adults with major medical problems, including ASA Physical Status III and above, have higher risks of adverse events.

Anesthesia and Sedation Definitions

Deep Sedation

DefinitionA drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.

Ventilatory functionThe ability to independently maintain ventilatory function may be impaired; spontaneous ventilation may be inadequate.

Airway supportPatients may require an advanced airway to maintain a patent airway.

Cardiovascular functionCardiovascular function is usually maintained.

General Anesthesia

DefinitionA drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.

Policy Summary

PayerUnitedHealthcare

PolicyGeneral Anesthesia and Conscious Sedation Services

Policy CodePolicy DCP016.19

Change TypeNo material clinical or coverage change

Effective DateSeptember 1, 2026

Next Review DateNot specified

Key ActionEnsure a designated individual other than the proceduralist monitors the patient throughout sedated procedures.

SourceLink

On This Page

Management of a severe gag reflex when nitrous oxide is ineffective or not indicated.

Pain control when other techniques have proven inadequate.

Pediatric patients and adults with major medical problems (ASA Physical Status III or above) are at higher risk of adverse events; obtain evaluation by a primary care physician or physician anesthesiologist before scheduling when recommended, particularly for high-risk patients and younger pediatric patients.
For prolonged or extensive procedures requiring longer sedation or anesthesia, qualified anesthesia providers should consider a more suitable facility in consultation with the patient.
Ensure personnel trained in advanced resuscitative techniques, such as ACLS or PALS, are immediately available until all patients are discharged home.
Assign a designated individual, other than the person performing the procedure, to monitor the patient throughout sedation procedures. During deep sedation or general anesthesia, this monitor must have no other responsibilities.
Maintain a reliable oxygen source, suction, resuscitation equipment, and emergency drugs.
Maintain protocols for accessing emergency medical services, managing life-threatening complications, and providing emergency life support and rescue services.

Ventilatory functionThe ability to independently maintain ventilatory function is often impaired.

Airway and ventilationPatients often require an advanced airway to maintain a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.

Cardiovascular functionCardiovascular function may be impaired.

Local Anesthesia

DefinitionThe elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.

Moderate Sedation (Conscious Sedation)

DefinitionA drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

AirwayNo interventions are required to maintain a patent airway.

Spontaneous ventilationSpontaneous ventilation is adequate.

Cardiovascular functionCardiovascular function is usually maintained.

Nitrous Oxide

DefinitionA colorless, odorless to sweet-smelling inorganic gas that, when combined with oxygen, can be a safe and effective means of managing pain and anxiety.

Clinical useWhen combined with oxygen, nitrous oxide may be used to manage pain and anxiety.

Non-Intravenous Sedation

DefinitionSedation medications that are delivered through the oral, intranasal, or transmucosal routes.

Medication delivery routesOral, intranasal, or transmucosal.