Clinical Policy: IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures Form

# Clinical Policy: IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures
Reference Number: CP.MP.61  
Date of Last Revision: 08/24  

[Coding Implications](Coding Implications)  
[Revision Log](Revision Log)  

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.  

## Description  
The administration of intravenous moderate sedation and intravenous deep sedation/general anesthesia in the dental office, inpatient hospital, or ambulatory surgical center may be necessary to safely provide dental care. These procedures generally are safe when administered by trained, certified providers in the appropriate setting but are not without risk. According to the American Academy of Pediatrics and the American Academy of Pediatric Dentistry (AAPD), the sedation of children is different from the sedation of adults, and the in-office use of deep sedation or general anesthesia may be appropriate on select pediatric dental patients administered in appropriately equipped and staffed facilities. Pediatric patients are subject to higher risk of adverse outcomes with sedation.  

## Policy/Criteria  
  
B. None of the following:  
1. Member/enrollee has predisposing medical and/or physical conditions that would make general anesthesia unsafe;  

II. It is the policy of health plans affiliated with Centene Corporation that in-office IV sedation or general anesthesia is **medically necessary** and the appropriate venue when the general criteria in section I. are met, the member/enrollee has no significant medical comorbidities and any of the following:  
A. Member/enrollee exhibits moderate or situational anxiety;  
B. Pediatric member/enrollee with limited treatment need (four to six teeth requiring restoration, pulpotomy, or extraction);  
C. Pediatric member/enrollee has social impact conditions necessitating completion of all treatment needs during a single visit;  
D. Pediatric member/enrollee under the age of eight with medically necessary dental services and with an ASA I or II classification;  
E. Pediatric member/enrollee under the age of eight with medically necessary dental services and with an uncompromised airway;  
F. Member/enrollee requires extraction of two or more impacted teeth in two or more quadrants;  
G. Member/enrollee requires extraction of two or more permanent teeth per quadrant involving two or more quadrants.  

III. It is the policy of health plans affiliated with Centene Corporation that ambulatory surgical center (ASC) or hospital out-patient IV sedation or general anesthesia is **medically**  

necessary and the appropriate venue when the general criteria in section I. are met and any of the following:  
A. Member/enrollee has compromising medical comorbidities;  
B. Local factors (e.g., access to care) or state regulations permit treating cases in an ASC that meet in-office approval conditions;  
C. Pediatric member/enrollee with extensive treatment needs (seven or more teeth requiring restoration, pulpotomy, or extraction of primary teeth);  
D. Pediatric member/enrollee with a combination of at least four teeth requiring restoration, pulpotomy, or extraction of primary teeth and the presence of at least one major medical comorbidity (e.g., documented anxiety disorder, uncontrolled asthma, pre-combative or combative behavior);  
E. Pediatric member/enrollee with social impact conditions necessitating completion of all treatment needs during a single visit and in-office IV sedation or general anesthesia is not accessible;  
F. Pediatric member/enrollee with social impact conditions necessitating completion of all treatment needs during a single visit in combination with a major medical comorbidity;  
G. Pediatric member/enrollee under the age of eight years with medically necessary dental services meeting clinical criteria and with an ASA III or IV classification;  
H. Pediatric member/enrollee under the age of eight years with medically necessary dental services and a compromised or obstructed airway;  
I. Member/enrollee requires extraction of two or more impacted teeth in two or more quadrants in combination with a major medical comorbidity;  
J. Member/enrollee requires extraction of two or more permanent teeth per quadrant involving two or more quadrants in combination with a major medical comorbidity.  

### Background  
#### Guidelines  
According to the American Dental Association (ADA), dentists must comply with their state laws, rules and/or regulations when providing sedation and anesthesia and follow the educational and training requirements for the level of sedation intended. The ADA maintains clinical guidelines and educational/training requirements for all levels of sedation and includes specific information for the following:  
- Patient history and evaluation  
- Pre-operative preparation  
- Personnel and equipment requirements  
- Monitoring and documentation (including consciousness, oxygenation, ventilation, and circulation)  
- Recovery and discharge  
- Emergency management  

Providers are encouraged to embrace and utilize the following American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Society of Anesthesiologists (ASA), Society for Pediatric Anesthesia, American Society of Dentist Anesthesiologists, and Society for Pediatric Sedation guidelines and/or recommendations.¹  

- High-risk patients and pediatric patients under the age of eight should be evaluated by a primary care physician or physician anesthesiologist prior to scheduling a procedure.  
- Prolonged and extensive procedures with longer periods of sedation and anesthesia care are of concern in the office-based setting, and qualified anesthesia providers, in consultation with such patients, should consider more suitable facilities for the procedure.  
- The sedation must be administered by a qualified anesthesia provider (a medical anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist or second oral surgeon). At a minimum, the sedation provider must be able to provide advanced pediatric life support (PALS) and capable of rescuing a child with apnea, laryngospasm, and airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, laryngeal mask airway) and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation.  
- A second observer, who is also skilled, and PALS certified, must also be present to assist with the anesthetic emergency while additional support is summoned; this is particularly critical in a dental office-based setting as the only backup is to call 911.  
- PALS-certified observers should be present to monitor the patient throughout procedures performed with sedation and have no other responsibilities during deep sedation and/or general anesthesia.  
- Oral surgeons and other dental practitioners who provide intravenous deep sedation or general anesthesia should discontinue the use of the single provider/operator model for the care of pediatric patients under the age of eight when sedated in dental offices.  

#### Drugs, Medicaments, and Gases  
Drugs, medicaments, and gases are used for the following levels of anxiolysis/analgesia, oral conscious sedation, IV moderate sedation, IV deep sedation/general anesthesia and include, but are not limited to the following:  

| Anxiolysis/Analgesia | IV Deep Sedation/General Anesthesia |
|---------------------|-----------------------------------|
| - Nitrous oxide and oxygen | - Propofol |
| Oral Conscious Sedation | - Benzodiazapine |
| - Midazolam – Schedule IV | - Ketamine – Schedule III |
| - Hydroxyzine | - Dexmedetomidide |
| - Diphenhydramine | - Sevoflurane |
| IV Moderate Sedation | - Desflurane |
| - Benzodiazapine | - Isoflurane |
| - Opioids – Schedule II | - Methohexital – Schedule IV |
| | - Succinylcholine |
| | - Opioids – Schedule II |

#### Sedation/General Anesthesia Definitions  
**IV Moderate Sedation:** A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.  

**IV Deep Sedation:** A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation (e.g., purposefully pushing away the noxious stimuli). Reflex withdrawal from a painful stimulus is not considered a purposeful response and is more consistent with a state of general anesthesia. The ability to maintain ventilator function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.  

**General Anesthesia:** A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain respiratory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.  

#### Coding Implications  
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

This clinical policy references Current Dental Terminology (CDT®). CDT® is a registered trademark of the American Dental Association. All CDT codes and descriptions are copyrighted 2023, American Dental Association. All rights reserved. CDT codes and CDT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

#### Coding Limitations/Exclusions  
1. One D9222 or D9239 per date of service.  
2. More than four units of D9223 or D9243 per date of service requires a copy of the sedation log, subject to state-specific regulations.  

| CPT® Codes | Description |
|------------|-------------|
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified |
| 00190 | Anesthesia for procedures on facial bones or skull; not otherwise specified |

| CDT® Codes | Description |
|------------|-------------|
| D9222 | Deep sedation/general anesthesia – first 15 minutes |
| D9223 | Deep sedation/general anesthesia – each subsequent 15-minute increment |
| D9239 | Intravenous moderate (conscious) sedation/analgesia – first 15 minutes |
| D9243 | Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment |
| D9248 | Non-intravenous conscious sedation |

#### Reviews, Revisions, and Approvals  

| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|---------------|---------------|
| Policy developed |  | 06/13 |
| References reviewed and updated | 03/20 | 03/20 |
| Annual review. References reviewed and updated. Replaced all instances of member with member/enrollee. Specialist reviewed. | 02/21 | 03/21 |
| Annual review. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” | 10/21 | 10/21 |
| Changed title from “Dental Anesthesia” to “IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures” and adopted the Evolve Dental Policy criteria from ENV.D.UM.CP.0009, approved 11/21. Removed HCPCS code D9230. Minor rewording with clinical significance. Specified that general criteria in I. must be met in addition to POS-specific criteria in II or III. Clarified in I. that A (indications), B (lack of contraindications), and C (documentation) must all be met. Specified in II that absence of comorbidities applies to all indications. Moved professional society guidelines/recommendations, list of sedation/anesthesia drugs, and definitions to the background. | 10/22 | 10/22 |
| References reviewed, updated, and reformatted. |  |  |
| Annual Review. In I.A. replaced “any” with “one or more” with no impact to criteria. Combined I.C.1. and I.C.2. Background: added “pre-operative preparation” and restructured wording with no impact to criteria. Added CDT disclaimer under coding implications. References reviewed and updated. Reviewed by internal specialist. | 10/23 | 10/23 |
| Annual review. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist. | 08/24 | 08/24 |

  

#### Important Reminder:  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health  

plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.  

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.  

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.  

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.  

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.  

**Note:** For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.  

**Note:** For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria  

set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.  

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