ModifiedWellpointPolicy 09-201

Anesthesia

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This policy governs coverage considerations, medical necessity, clinical criteria, monitoring, documentation, and coding for local anesthesia, nitrous oxide, conscious sedation, deep sedation, and general anesthesia provided with dental services. It applies to dental providers and members, subject to the member's contract benefits and applicable federal and state law.

Policy Summary

PayerWellpoint

PolicyAnesthesia

Policy CodePolicy 09-201

Change TypeModified — minor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

Key ActionFor office anesthesia exceeding 60 minutes, submit written rationale, radiographic images, progress notes, an operative report, and a complete anesthesia record showing start and stop times of incremental drug administration.

SourceLink

POLICY UPDATE CHANGES

The policy was revised on October 31, 2023 with minor editorial refinements to the description, clinical indications, criteria, and references.

60 minOffice anesthesia documentation threshold

5Qualifying clinical situations

4Nitrous oxide indications

4Nitrous oxide contraindication categories

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ModifiedWellpointPolicy 09-201

Anesthesia

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Policy Summary

PayerWellpoint

PolicyAnesthesia

Policy CodePolicy 09-201

Change TypeModified — minor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The policy was revised on October 31, 2023 with minor editorial refinements to the description, clinical indications, criteria, and references.

60 minOffice anesthesia documentation threshold

5Qualifying clinical situations

4Nitrous oxide indications

4Nitrous oxide contraindication categories

10Anesthesia-related dental codes

Covered Dental Anesthesia and Sedation

Deep sedation, general anesthesia, and conscious sedation

Deep sedation, general anesthesia, IV moderate conscious sedation, and non-IV conscious sedation may be benefitted when appropriate in conjunction with covered dental services and when at least one qualifying criterion is met.

General coverage conditions

Qualifying clinical situations
- Child with complex dental condition: The member is a child up to the age defined by contract and has a dental condition, such as Early Childhood Caries, requiring repairs of significant complexity, including multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions, combinations of these procedures, or other dental procedures.
- Physical, intellectual, or medically compromising condition: The member has a physical, intellectual, or medically compromising condition for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and treatment under anesthesia can be expected to produce a superior result.
  Examples include intellectual disabilities, cerebral palsy, epilepsy, severe cardiac problems, and hyperactivity; appropriate medical documentation is required.
- Extreme uncooperativeness or anxiety with complex needs: The member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative, has complex dental needs that should not be postponed or deferred, and lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral morbidity.
- Ineffective local anesthesia: Local anesthesia is ineffective because of circumstances such as acute infection, anatomic variation, or allergy.
  Failed attempts at local anesthesia administration must be documented and submitted for review.
- Extensive oral-facial or dental trauma: The member has sustained extensive oral-facial and/or dental trauma for which treatment under local anesthesia would be ineffective or compromised.
Concurrent covered dental treatment: The anesthesia is performed in conjunction with a covered dental service.

Nitrous oxide indications

Nitrous oxide may be benefitted when appropriate in conjunction with covered dental services.

Ineffective local anesthesia: Local anesthesia administration is ineffective.
Dental anxiety: The patient has dental anxiety.
Special needs: The patient has special needs.
Uncooperative or behaviorally challenged patient: The patient is uncooperative or behaviorally challenged.

Local anesthetic administration is considered inclusive of all dental procedures and is not eligible for a separate benefit unless the member’s specific plan allows separate coverage.

Regional and trigeminal division block anesthesia may not be a covered service. Coverage remains subject to the member’s contract benefits.

Nitrous oxide is contraindicated for patients with severe respiratory compromise, during the first trimester of pregnancy because of potential teratogenic effects, for patients with a history of stroke, and for patients with hypotension or known cardiac conditions. These contraindications are not limited to the listed categories.

Anesthesia Coding and Duration Rules

Local, regional, and trigeminal block anesthesiaCPT

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

Sedation, general anesthesia, nitrous oxide, and related dental codesCPT

D9219	evaluation for deep sedation or general anesthesia
D9222	deep sedation/general anesthesia - first 15 minutes
D9223	deep sedation/general anesthesia - each 15 minute increment
D9230	inhalation of nitrous oxide/analgesia, anxiolysis
D9239	intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243	intravenous moderate (conscious) sedation/analgesia - each 15 minute increment
D9248	non-intravenous conscious sedation
D9613	infiltration of sustained release therapeutic drug, per quadrant

Office anesthesia duration

Duration thresholdOffice anesthesia in excess of 60 minutes

Required rationaleWritten rationale and documentation explaining the necessity are required.

Supporting documentationSubmit associated radiographic images, progress notes, an operative report, and a complete anesthesia record showing start and stop times of incremental drug administration.

Contract-defined pediatric age

Applicable ageThe age defined by the member's contract and applicable state-mandated criteria

Intravenous anesthesiaContract-defined pediatric age applies for intravenous (IV) anesthesia.

Documentation and Provider Requirements

Documentation Required

Medical Condition Support Required

Submit physician medical documentation supporting any physical, intellectual, or medically compromised condition that necessitates general anesthesia or conscious sedation. Documentation must establish why treatment with local anesthesia cannot be expected to provide a successful result; supporting documentation may be submitted by the oral surgeon, dentist, and/or physician administering anesthesia.

Examples include intellectual disability, cerebral palsy, epilepsy, severe cardiac problems, and hyperactivity when verified by appropriate medical documentation.
General anesthesia or conscious sedation must be performed in conjunction with covered dental surgical services other than oral surgery, when medically necessary due to the concurrent condition.

Documentation Required

Document Failed Local Anesthesia Attempts

When local anesthesia is ineffective because of acute infection, anatomic variation, allergy, or another documented reason, document and submit the failed local-anesthesia attempts for review before requesting the general anesthesia or conscious sedation benefit.

Dental Anesthesia and Sedation Overview

Dental anesthesia services span a continuum from minimal sedation through moderate sedation, deep sedation, and general anesthesia. The appropriate level is determined by the anesthetic agent’s effect on the central nervous system rather than solely by its route of administration. Patient age, medical or developmental conditions, behavior, anxiety, the likelihood that local anesthesia will be effective, and the extent or complexity of the dental treatment may influence the level selected. More advanced anesthesia may be appropriate when local anesthesia is unlikely to produce a successful treatment outcome; deep sedation and general anesthesia may impair airway protection and spontaneous breathing, while moderate and minimal sedation generally preserve spontaneous breathing and cardiovascular function.

Anesthesia and Sedation Definitions

General anesthesia

DefinitionA drug-induced loss of consciousness in which the patient is unarousable, even by painful stimulation.

Airway and breathingThe patient often requires assistance to maintain the airway and may need positive-pressure ventilation because spontaneous breathing or neuromuscular function may be depressed.

Cardiovascular functionCardiovascular function might also be impaired.

Deep sedation/analgesia

DefinitionA drug-induced depression of consciousness in which the patient is not easily aroused.

Response to stimulationThe patient responds purposefully after repeated or painful stimulation.

Policy Summary

PayerWellpoint

PolicyAnesthesia

Policy CodePolicy 09-201

Change TypeModified — minor editorial refinements

Effective Date01/01/2025

Last ReviewOct 31, 2024

Next Review DateN/A

SourceLink

On This Page

Inhalation anesthesiaContract-defined pediatric age applies for inhalation anesthesia.

The member must have a condition for which local anesthesia, with or without adjunctive techniques or modalities, cannot be expected to provide a successful result.

Document the reason local anesthesia failed and the attempts made.

Documentation Required

Maintain a Complete Anesthesia Record

Maintain a complete anesthesia record identifying every anesthetic drug administered, the time of administration, and the dosage, including local anesthetics and intravenous or inhaled anesthetic drugs. Record and retain all physiologic parameters monitored throughout the service.

The anesthesia record must be complete and contemporaneous.
The level of anesthesia is determined by the documented effect of the anesthetic agent on the patient's central nervous system, not by the route of administration.

Unsupported block type: documentation

Billing Rule

Local Anesthesia Is Generally Bundled

Local anesthetic administration—including traditional, electronic, buffered, or similar forms—is inclusive of the dental procedure and is not eligible for a separate benefit unless the member's specific plan expressly allows separate coverage.

This rule applies to local anesthesia not in conjunction with operative or surgical procedures and local anesthesia used in conjunction with operative or surgical procedures.
Review the member's contract before billing local anesthesia separately.

Denial Risk

Block Anesthesia May Not Be Covered

Regional and trigeminal division block anesthesia may not be a covered service. Verify the member's contract and benefit terms before performing or billing these services.

CDT D9211: regional block anesthesia.
CDT D9212: trigeminal division block anesthesia.

Unsupported block type: denial_risk

Airway and cardiovascular effectsAirway assistance may be required and spontaneous breathing may be inadequate; cardiovascular function is generally preserved.

Intravenous moderate conscious sedation/analgesia

DefinitionA drug-induced depression of consciousness used to help the patient feel relaxed and calm.

ResponsivenessThe patient remains awake and able to follow directions, and typically remembers little to nothing of the procedure.

Physiologic functionNo airway interventions are necessary, spontaneous breathing is adequate, and cardiovascular function is usually maintained.

Minimal sedation/anxiolysis

DefinitionA drug-induced state of consciousness that allows the patient to respond normally to verbal commands.

Cognitive and motor effectsCognitive function and coordination may be impaired.

Physiologic effectsThe patient maintains airway reflexes, breathing, and cardiovascular function.

Time of general anesthesia

Start pointThe time of general anesthesia begins when the dentist starts administering the sedative agent and the non-invasive monitoring protocol.

End pointServices are complete when the patient may be safely left under the observation of trained personnel.

Dentist attendanceThe dentist must remain in constant attendance until completion of the anesthesia procedure and may then safely leave the operatory to attend to other patients.