II-166-009

Medical Policy:

II-166-009

Topic:

General Anesthesia Services for Dental Procedures

Section:

Medicine

Effective Date:

February 1, 2021

Issued Date:

February 1, 2021

Last Revision Date:

November 2020

Annual Review:

November 2020

This policy version was replaced on January 31, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

This policy addresses general anesthesia services during dental procedures. It does not address anesthesia services for diagnostic or therapeutic procedures other than dental procedures. General anesthesia services include all services associated with the administration and monitoring of general anesthesia to a patient in order to produce complete loss of sensation.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

I. General anesthesia services during dental procedures may be considered MEDICALLY NECESSARY AND APPROPRIATE for patients who meet ANY of the following criteria:

Under 5 years of age; OR
Presence of a severe disability, including but not limited to:
- Epilepsy or a history of seizures;
- Mental health disorders (e.g., autism, schizophrenia);
- Chromosomal abnormalities (e.g., Down's syndrome, trisomy);
- Cerebral palsy. OR
Presence of a serious underlying medical condition, including but not limited to:
- Respiratory conditions (e.g., severe asthma);
- Cardiac conditions (e.g., arrhythmias, congestive heart failure, cardiac anomalies);
- Bleeding disorders which could lead to immediate or severe airway compromise;
- Conditions with known or suspected airway compromise. OR
Requires immediate, comprehensive oral/dental care (e.g., dental abscess threatening patency of the airway); OR
Requires significant restorative and/or surgical procedures (e.g., 5 or more dental procedures performed simultaneously); OR
Local anesthesia is contraindicated because of acute infection, anatomic variations, or allergy; OR
Other methods of basic and advanced behavior guidance in the dental office have been tried and were unsuccessful (e.g., communication techniques, parental presence/absence, nitrous oxide/oxygen inhalation, protective stabilization, sedation).

II. General anesthesia services during dental procedures are considered NOT MEDICALLY NECESSARY for patients who do not meet the medical necessity criteria described above.

D9222 D9223 00170 00172 00174 00176

Coverage

General anesthesia services for dental procedures are covered only when performed by properly-trained and credentialed anesthesia personnel, who are not also performing the primary procedure.

Denial Statements

No additional statements.

Links

Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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