This policy version was replaced November 27, 2023. 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 anesthesia services during dental procedures. It does not address anesthesia services for diagnostic or therapeutic procedures other than dental.  Anesthesia services include all services associated with the administration and monitoring of general anesthesia or monitored anesthesia care (MAC) (i.e., deep sedation with anesthesia) to a patient in order to produce complete loss of sensation.

I.  General anesthesia or monitored anesthesia care (MAC) 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; 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 or MAC services during dental procedures are considered NOT MEDICALLY NECESSARY for patients who do not meet the medical necessity criteria described above.

Coverage

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.

Documentation Submission:

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

1. Clinical notes describing the diagnosis and clinical features of the diagnosis.
2. Clinical notes describing previous attempts to provide dental care in the office.
3. Clinical notes describing previous attempts to provide basic and advanced behavioral modification.
4. If applicable, clinical notes from the patient's medical provider describing a severe disability or serious medical condition that requires general anesthesia or MAC services. This must include documentation pertaining to severity of the disability or condition.
5. If applicable, documentation of significant restorative and/or surgical procedures to be performed.
6. If applicable, documentation of contraindication to local anesthesia.