Anesthesia for Dental Services
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This UHA reimbursement policy governs when anesthesia (general anesthesia or monitored anesthesia care) for dental and oral/maxillofacial procedures is considered medically necessary and reimbursable, and outlines related limitations, prior authorization, and billing guidance for providers.
No material clinical or coverage changes in this revision.
When Anesthesia for Dental/Oral-Maxillofacial Procedures Is Medically Necessary
Medical necessity criteria
UHA considers general anesthesia and monitored anesthesia care medically necessary for dental or oral-maxillofacial surgery services when ONE OR MORE of the following criteria are met:
ANY of the following
- The member is a child up to 6 years old with a dental condition requiring repair of significant complexity (examples: baby‑bottle caries; multiple amalgam and/or resin‑based composite restorations, pulpal therapy, extractions, or combinations of these procedures).
- Members who exhibit physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia (with or without adjunctive techniques) cannot be expected to provide a successful result, and for whom treatment under anesthesia can be expected to produce a superior result (examples include, but are not limited to: mental retardation, cerebral palsy, epilepsy, cardiac problems, hyperactivity). Appropriate medical documentation is required.
- Members who are extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative, whose dental needs are of such magnitude that treatment should not be postponed and for whom lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral/dental morbidity.
- Members for whom local anesthesia is ineffective (for example, due to acute infection, anatomic variations, or allergy).
- Members who have sustained extensive oral‑facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.
- Members requiring treatment of bony impacted wisdom teeth.
Covered Anesthesia Codes
| 00170-00176 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery. |
| 00190-00192 | Anesthesia for procedures on facial bones or skull |
Prior Authorization, Documentation, and Reconsideration
Prior authorization required; submit PA form via UHA portal
Prior authorization is required before reimbursement will be considered. To request prior authorization, complete the PA form specific to psychological and neuropsychological testing and submit it via UHA's online portal; if you do not have a portal login, contact UHA at 808-532-4000 to establish one.
- Complete the PA form specific to psychological and neuropsychological testing.
- Submit the completed form through UHA's online portal.
- Call 808-532-4000 to establish a portal login if needed.
Retrospective review and reconsideration process
UHA reserves the right to perform retrospective review to validate that services rendered met the payment determination. Providers may request reconsideration of medical necessity determinations by submitting supporting documentation through direct peer communication.
- Retrospective review may be conducted by UHA to validate services against the policy criteria.
- To request reconsideration, provide supporting documentation and engage in direct peer communication with UHA.
Check benefit plan and state mandates for coverage
Coverage and availability of monitored anesthesia care or general anesthesia for dental treatments may be impacted by specific benefit plan language and state mandates; providers must refer to the applicable plan benefit document to determine coverage and terms.
- Check the member's benefit plan document for coverage details and any limitations.
- Consider state mandates that may govern benefit availability for anesthesia with dental treatment.
Definitions and Setting Limitations
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