Prior authorization request form Form

Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery

Last Review Date: May 8, 2026 
Number: MG.MM.ME.66C7

Medical Guideline Disclaimer The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Methods of Anxiety and Pain Control Deep Sedation/Analgesia Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. General Anesthesia Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory 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. Minimal Sedation (“Anxiolysis”) Drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.
Moderate Sedation/Analgesia
(“Conscious Sedation”) 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. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. (See Moderate Sedation Coding Note)

Related Medical Guideline Dental Care or Treatment Necessary Due to Congenital Disease Dental Trauma Guidelines for Medical Plans Orthognathic Surgery Guideline General anesthesia and MAC are considered medically necessary components of dental and oromaxillofacial surgical procedures when the procedure or surgery is covered under the member’s benefit package* and when any of the following criteria are met:

1. Member is ≤ 6 years of age with a dental condition that requires repairs of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions or any combinations of these noted or other dental procedures).
2. Member exhibits physical/mental behaviors that would likely impede the successful completion of treatment(s) without the use of anesthesia. (E.g., diagnoses such as mentally impaired, cerebral palsy, epilepsy, cardiac problems, hyperactivity, etc.)
3. Member has severe dental needs, but is either uncommunicative, extremely uncooperative, fearful, unmanageable or anxious, such that the deferment or postponement of treatment would be likely result in dental/oral pain, infection, loss of teeth or other increased oral or dental morbidity.
4. Allergy or sensitivity to local anesthesia.
5. Member has sustained extensive oral-facial/dental trauma for which treatment under local anesthesia would be ineffective or compromised.

6. Excision of bony impacted wisdom teeth is required.

   Limitations/Exclusions

7. Anesthesia is only covered for dental procedures listed as covered benefits.
8. For claims remittance, the medical benefit applies if an anesthesiologist, Doctor of Dental Surgery (DDS), Doctor of Medicine in Dentistry or Doctor of Dental Medicine (DMD), submits a claim and the above criteria are met.
9. Local Anesthesia is considered an inclusive component of any dental procedure for pain control.
10. Commensurate with the American Society of Anesthesiologists' standards for monitoring, MAC should be provided by qualified anesthesia personnel, (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists or anesthesia assistants). These individuals must be continuously present to monitor the member and provide anesthesia care. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the member loses consciousness and the ability to respond Monitored Anesthesia Care (MAC) Planned procedure during which the patient undergoes local anesthesia together with sedation and analgesia. MAC includes all aspects of anesthesia care – a preprocedure visit, intraprocedure care and postprocedure anesthesia management. (MAC does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.”)

purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.

5. Coverage of nitrous oxide and intravenous (IV) sedation is limited to once per day. (More than once per day is allowable when sedation or general anesthesia is administered for the purposes of a distinct procedure performed on an urgent or emergent basis, on the same day, following recovery from initial sedation or anesthesia. In rare cases, complications of a dental or oral/maxillofacial surgery may necessitate urgent or emergent re-operation on the same day).
6. Nitrous oxide is excluded when reported on same date of service as IV sedation, non-IV sedation or general anesthesia. Non-IV sedation is not allowed on the same day as general anesthesia.

7. Reimbursement for anesthesia services by the servicing provider will not be paid.

   Applicable Procedure Codes 00100 Anesthesia for procedures on salivary glands, including biopsy 00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified 00172 Anesthesia for intraoral procedures, including biopsy; repair of cleft palate 00174 Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor 00176 Anesthesia for intraoral procedures, including biopsy; radical surgery 00190 Anesthesia for procedures on facial bones or skull; not otherwise specified 00192 Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism) References American Academy of Pediatric Dentistry Policy on the Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office. Revised 2023. https://www.aapd.org/link/e23cd5aea5424cb7868bbe98bea944f6.aspx. Accessed May 12, 2026. American Academy of Pediatrics; American Academy on Pediatric Dentistry. Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. https://www.aapd.org/globalassets/media/policies_guidelines/bp_monitoringsedation.pdf. Accessed May 12, 2026. American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on Use of Nitrous Oxide for Pediatric Dental Patients. Revised 2023. http://www.aapd.org/media/policies_guidelines/g_nitrous.pdf. Accessed May 12, 2026. American Dental Association Policy Statement: The use of Sedation and General Anesthesia by Dentists. 2007. http://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/ADA_Sedation_Policy_Statement.pdf?la=en. Accessed May 12, 2026. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. October 2014, last amended October 2023. https://www.asahq.org/standards-and-practice- parameters/statement-on-continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia. Accessed May 12, 2026. Dent Clin North Am. 2016 Apr;60(2):309-46. doi: 10.1016/j.cden.2015.11.009. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Southerland JH1, Brown LR2.
   J Am Dent Assoc. 2015 Sep;146(9):705-8. doi: 10.1016/j.adaj.2015.04.005. How safe is deep sedation or general anesthesia while providing dental care? Bennett JD, Kramer KJ, Bosack RC. Specialty matched clinical peer review.