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Coverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services
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This policy governs medical coverage of outpatient facility/ambulatory surgery unit (ASU) services and anesthesia for dental procedures (not dental benefits) for Univera Healthcare members.
Code edit: added CDT codes D9224 and D9225.
Policy title and initial policy statement were edited to include 'outpatient facility' for clarification and alignment of policy content.
Annual review noted with policy intent unchanged.
Coverage Criteria for ASU/Outpatient Facility and Anesthesia for Dental Services
Covered indications (ANY of the following)
Services at an outpatient facility or ambulatory surgery unit, including anesthesia by an anesthesiologist, are considered medically appropriate when ANY of the following are met:
Covered indications
- Indication A: Age seven years or younger.
- Indication B: Developmental disability, when treatment has been unsuccessful in the traditional dental setting.
- Indication C: Concurrent hazardous medical condition(s) with medical documentation and justification, subject to review by a Health Plan Medical Director, that the service must be rendered in an ambulatory surgery unit (ASU) setting and not in the traditional setting.
- Indication D: Behavioral management issues with documentation of an unsuccessful attempt to treat in the dental office after the use of a sedation modality (e.g., oral sedation, nitrous oxide).
For developmental disability and behavioral severity, the Health Plan may waive the requirement for attempted in-office treatment if, in the judgment of the Health Plan, it is inappropriate to treat the patient in the dental office due to the developmental disability, severity of behavioral issues, or complexity of the treatment planned.
This policy governs medical coverage for services provided in an outpatient facility or ambulatory surgery unit (ASU) and associated anesthesia for dental procedures under Univera Healthcare medical plans. Dental benefits are excluded; services that are the responsibility of a member's dental plan are not covered by this medical policy. Providers should submit dental-plan questions to the member's dental carrier rather than to the medical plan.
There are no National or Regional Medicare coverage determinations specifically addressing Ambulatory Surgery Unit (ASU) services or anesthesia for dental surgery. While CMS has issued communications about ambulatory surgery units and anesthesia generally, CMS does not specifically address coverage for ASU and anesthesia for dental surgery.
Relevant Billing and Procedure Codes
| G0330 | Facility 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 |
| D9224 | Initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Administration of general anesthesia with advanced airway - each subsequent 15 |
| D9225 | Referenced as added in change log (specific description not included in source). |
| E08.630 | Diabetes mellitus due to underlying condition with periodontal disease |
| E09.630 | Drug or chemical induced diabetes mellitus with periodontal disease |
| E10.630 | Type 1 diabetes mellitus with periodontal disease |
| E11.630 | Type 2 diabetes mellitus with periodontal disease |
| E13.630 | Other specified diabetes mellitus with periodontal disease |
| K00.0-K01.1 | Disorder of tooth development (code range) |
| K02.3-K02.9 | Dental caries (code range) |
| K03.0-K03.9 | Diseases of hard tissues of teeth (code range) |
| K04.0-K04.99 | Diseases of pulp and periapical tissues (code range) |
| K05.0-K06.9 | Disorders of gingiva and supporting structures (code range) |
| (E/I) | Experimental/Investigational |
| (NMN) | Not medically necessary/appropriate |
Provider Requirements, Documentation, and Authorization
Anesthesiologist must render anesthesia in ASU/outpatient facility
Anesthesia provided in an outpatient facility or ambulatory surgical unit is eligible for coverage only when rendered by an anesthesiologist.
Prior authorization and coverage depend on product/contract
Prior authorization and coverage depend on the member's product and contract; if a product does not cover a service, medical policy criteria do not apply. When a product does cover the service, medical policy criteria and any applicable prior authorization requirements for that product apply.
- Services are contract dependent; if a product does not cover a service, medical policy criteria do not apply.
- If a commercial product covers a specific service, medical policy criteria apply to the benefit.
- If a Medicaid or Medicare product covers a service without specific guidelines/decisions, medical policy criteria apply.
Attempted in‑office sedation required before ASU for behavioral issues
For behavioral management indications, coverage is indicated only when documentation shows an unsuccessful attempt to treat the patient in the dental office after use of a sedation modality (e.g., oral sedation, nitrous oxide), unless the Health Plan judges an in‑office attempt inappropriate.
- Coverage requires documentation of an unsuccessful in‑office treatment attempt following use of a sedation modality (oral sedation, nitrous oxide).
- Health Plan may waive the attempted in‑office requirement if it judges office treatment inappropriate due to developmental disability, behavioral severity, or treatment complexity.
No step therapy requirements specified
This policy states no step therapy requirements are specified in the document.
Medical record documentation required when in‑office treatment was unsuccessful or inappropriate
When there has been an unsuccessful attempt to treat in the dental office, or when in‑office treatment is inappropriate due to behavioral severity, hazardous medical condition severity, or treatment complexity, the medical record must document the treatment plan, the patient's health history, date(s) treatment was attempted, and the patient's response.
- Documentation must include: treatment plan; patient health history; date(s) of attempted in‑office treatment; patient response to those attempts.
Documentation required to support CDT anesthesia billing (D9224)
For billing CDT D9224 (general anesthesia with advanced airway), provider documentation must support initiation of anesthesia and non‑invasive monitoring, presence/use of an advanced airway (e.g., laryngeal tube, laryngeal mask airway, endotracheal tube, Combitube), and continuous attendance until the patient may be safely left under observation of trained personnel.
- Document initiation of anesthesia and monitoring protocol and continuous attendance.
- Document presence/use of an advanced airway (supraglottic or subglottic devices listed).
- Record when patient may be safely left under observation and the provider may leave the room.
Missing documentation may lead to denial or review
Lack of the required medical record documentation (treatment plan, health history, dates attempted, and patient response) when an attempted dental office treatment failed or office treatment was inappropriate may lead to denial or require review.
Coverage for listed codes may be limited by circumstances and product
Codes listed in the policy (including CPT, HCPCS, and CDT codes) may not be covered under all circumstances; coverage and applicability depend on policy criteria and the member's product/contract.
- Codes may not be covered under all circumstances.
- Services are contract dependent; product coverage determines applicability of policy criteria.
Background
Anesthesia in dentistry — whether local, sedation, or general — is used to prevent pain and achieve loss of sensation or consciousness for dental procedures. This policy aligns clinical context with practical documentation and utilization expectations: when in-office treatment has been attempted unsuccessfully or when office-based care is inappropriate because of behavioral severity, hazardous medical conditions, or treatment complexity, medical record documentation must support the decision to use an ASU and anesthesia. Documentation should include the treatment plan, the patient's health history, the date(s) treatment was attempted, and the patient's response. The policy also references professional guidance on appropriate indications for general anesthesia in pediatric and special-needs patients and the requirement that anesthesia provided in an outpatient facility/ASU be rendered by an anesthesiologist per policy rules.
Definitions
Revision History and Policy Changes
Added CDT codes D9224 and D9225 to the policy change log.
Annual review noted; policy intent unchanged.
Policy edit: format correction recorded in revision history.
Policy title and initial policy statement were edited to include 'outpatient facility' for clarification and alignment of policy content.
Annual review noted; policy intent unchanged.
Summary of changes tracking implemented.
Original effective date of the policy.
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