Anthem Blue Cross Connecticut CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting Form

This document addresses the use of moderate to deep anesthesia services utilized in the facility setting when used to treat individuals undergoing dental procedures. This excludes the office setting.

Note: Please see the following related document for additional information:

• CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures

Clinical Indications

Medically Necessary:

1. The use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is considered medically necessary when the following criteria have been met:
   1. When extensive surgical procedures are required; and
   2. Submitted documentation (including narrative, radiographs, etc.) demonstrates the presence of any of the following circumstances:
      1. Hospitalized individuals; or
      2. Children under 6 years of age; or
      3. Individuals classified by the American Society of Anesthesiologists (ASA) as class III or class IV; or
      4. Individuals classified with a Mallampati score of 3 or 4; or
      5. Individuals with a medical history of uncontrolled bleeding, severe cerebral palsy, or another medical condition that renders in-office treatment not medically appropriate; or
      6. Individuals who have documentation of significant behavioral health conditions or psychiatric disorders that require special treatment (for example, severe panic disorder); or
      7. Cognitively disabled individuals whose prior history indicates hospitalization is appropriate.
2. The use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is considered medically necessary for medically compromised individuals when submitted documentation (including narrative, radiographs, etc.) demonstrates the potential changes in the individual’s clinical condition are such that immediate access to specific services of a medical center/hospital setting, having emergency resuscitation equipment and personnel, and inpatient admission or intensive care is necessary, for example, the individual is at significant risk of sudden life-threatening changes in medical status based on clinical conditions.
3. The use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is considered medically necessary for individuals with severe developmental, behavioral, or intellectual conditions that prevent the safe and effective delivery of dental services in another setting.

Not Medically Necessary:

The use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is considered not medically necessary when the above criteria have not been met, including but not limited to routine treatment of dental carries and non-impacted third molar extractions in the absence of other criteria listed above.