ModifieduniverahealthcarePolicy 7.03.01

Coverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services

Customize your policy alerts

Sign up for univerahealthcare Policy 7.03.01 alerts

Get alerted when Policy 7.03.01 changes without checking for updates manually.

Monitor payer policy activity

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

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.

Policy Summary

Payeruniverahealthcare

PolicyCoverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services

Policy CodePolicy 7.03.01

Change TypeAdded CDT codestitle clarifiedannual review

Effective DateMay 21, 2026

Last ReviewJul 30, 2026

Next Review DateMay 20, 2027

Key ActionAnesthesia in an outpatient facility or ambulatory surgical unit is eligible for coverage only when rendered by an anesthesiologist.

SourceLink

POLICY UPDATE CHANGES

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.

Age ≤ 7automatic indication for ASU/anesthesia coverage

Anesthesiologistanesthesiologist required

Medical recordsdocumentation required

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifieduniverahealthcarePolicy 7.03.01

Coverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services

Customize your policy alerts

Sign up for univerahealthcare Policy 7.03.01 alerts

Get alerted when Policy 7.03.01 changes without checking for updates manually.

Monitor payer policy activity

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

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.

Policy Summary

Payeruniverahealthcare

PolicyCoverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services

Policy CodePolicy 7.03.01

Change TypeAdded CDT codestitle clarifiedannual review

Effective DateMay 21, 2026

Last ReviewJul 30, 2026

Next Review DateMay 20, 2027

Key ActionAnesthesia in an outpatient facility or ambulatory surgical unit is eligible for coverage only when rendered by an anesthesiologist.

SourceLink

POLICY UPDATE CHANGES

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.

Age ≤ 7automatic indication for ASU/anesthesia coverage

Anesthesiologistanesthesiologist required

Medical recordsdocumentation required

D9224, D9225CDT anesthesia codes

00170, 41899Listed CPT codes

7.01.21related policy

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

CPT CodesCPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified.
41899	Unlisted procedure, dentoalveolar structures

HCPCS CodesHCPCS

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

CDT Codesmixed

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).

ICD-10 CodesICD-10

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)

1–10 of 15

1/2

Code annotationsmixed

(E/I)	Experimental/Investigational
(NMN)	Not medically necessary/appropriate

CDT D9224 time unit

Time unitEach subsequent 15-minute increment

Usage noteApplies to CDT code D9224 for billing additional time units beyond initiation

Documentation requirementProvider must document presence of an advanced airway and continuous attendance to support time-based units

Provider Requirements, Documentation, and Authorization

Prior 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

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.

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

Anesthesia

DefinitionAdministration of an anesthetic agent or anesthetic drug by injection, inhalation, or ingestion to achieve loss of sensation or loss of consciousness

PurposeUsed in dentistry to numb the patient and prevent pain during dental procedures

TypesIncludes local anesthesia, sedation, and general anesthesia

General anesthesia (AAPD context)

Indications (AAPD)Indicated for patients who cannot cooperate due to lack of psychological or emotional maturity or disability; when local anesthesia is ineffective or contraindicated; extremely uncooperative, fearful, or anxious patients; pre-communicative or noncommunicative children/adolescents; patients requiring significant surgical procedures combined with dental procedures; to protect the developing psyche or reduce medical risk; and for immediate, comprehensive oral/dental care (e.g., trauma, severe infection).

Revision History and Policy Changes

2026-07-30code editLatest

Added CDT codes D9224 and D9225 to the policy change log.

2026-05-21annual review

Annual review noted; policy intent unchanged.

2026-01-14format correction

Policy Summary

Payeruniverahealthcare

PolicyCoverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Services

Policy CodePolicy 7.03.01

Change TypeAdded CDT codestitle clarifiedannual review

Effective DateMay 21, 2026

Last ReviewJul 30, 2026

Next Review DateMay 20, 2027

Key ActionAnesthesia in an outpatient facility or ambulatory surgical unit is eligible for coverage only when rendered by an anesthesiologist.

SourceLink

On This Page

Step Therapy

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.

Step Therapy

No step therapy requirements specified

This policy states no step therapy requirements are specified in the document.

Documentation Required

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.

Billing Rule

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.

Denial Risk

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.

Note

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.

Contraindicated for healthy, cooperative patients with minimal dental needs, for convenience, or when predisposing medical conditions make general anesthesia inadvisable

Behavioral guidance contextAAPD notes general anesthesia may be used when non-pharmacologic behavior guidance techniques are ineffective; protective stabilization may be attempted when appropriate

G0330 (HCPCS) facility services for dental rehabilitation

DefinitionFacility services for dental rehabilitation procedures performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation [monitored anesthesia care]) and use of an operating room

CodeHCPCS G0330

Context of useBilled for facility-level services when dental rehabilitation requires monitored anesthesia and operating room resources

D9224 (CDT) general anesthesia with advanced airway

CodeCDT D9224

DescriptionInitiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient; administration of general anesthesia with advanced airway

Advanced airway examplesSupraglottic or subglottic airway device, laryngeal tube, esophageal-tracheal tube (Combitube), laryngeal mask airway, or endotracheal tube

Completion criterionAnesthesia services are considered completed when the patient may be safely left under observation of trained personnel and the doctor may safely leave the room

Policy edit: format correction recorded in revision history.

2025-06-12policy edit (clarification)

Policy title and initial policy statement were edited to include 'outpatient facility' for clarification and alignment of policy content.

2025-05-22annual review

Annual review noted; policy intent unchanged.

2025-01-01administrative

Summary of changes tracking implemented.

2001-10-18effective date

Original effective date of the policy.