Dental Anesthesia Form

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Dental Anesthesia - Medical Policy
Revision Effective: June 1, 2023 Policy Number:

UM948POL

Approval Date: 05/09/2023

Line(s) of Business:

FF
SF
Medicare
MedSupp-G
MedSupp-I
Medicaid

Description

This policy covers the use of anesthesia for dental procedures including inhalation of nitrous oxide/analgesia, anxiolytics, deep sedation, intravenous conscious sedation/analgesia, and non-intravenous conscious sedation. All general and intravenous sedation performed in conjunction with oral surgery procedures including, but not limited to, surgical extractions are subject to prior approval.

Policy

Medically Necessary

I. For pediatric patients under age 18:

General and intravenous anesthesia may be considered medically necessary for some but not all oral surgery and surgical extractions; some instances may include:

• Multiple extractions at the same time (5 or more)
• Multiple surgical extractions at the same time involving 2 lower-third molars
• Extraction of an abscessed tooth when local anesthesia would be ineffective
• Extensive restorative work on a child under the age of 7 (3 or more) • Extensive oral surgery procedures, e.g., removal of lateral exostoses or tori
• Underlying medical conditions necessitating GA or IV Sedation such as: o Autism or severe developmental delay o Congenital heart disease or pulmonary hypertension o Severe obstructive sleep apnea or airway malformation

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II. For adult patients age 18 and over:

Facility and Anesthesia charges for general and intravenous anesthesia may be considered medically necessary in the following settings:

• with phobias or mental illness documented by a licensed physician or mental health professional; OR
• with disabilities that preclude office-based dental care due to safety considerations; OR
• who are developmentally unable to safely tolerate office-based dental care; OR • Underlying medical conditions necessitating GA or IV Sedation o Autism or severe developmental delay o Congenital heart disease or pulmonary hypertension o Severe obstructive sleep apnea or airway malformation

NOTE: Professional charges for dental services may not be covered.

MassHealth Prior authorization is not required when a member is eligible for oral surgery services and when administered in the office only by a provider who possesses both an anesthesia-administration permit and an anesthesia-facility permit issued by the Massachusetts Board of Registration in Dentistry.

• General anesthesia or IV sedation may only be performed in conjunction with covered oral surgery and maxillofacial procedures. • MassHealth pays for the oral administration of analgesia as part of an operative procedure. • MassHealth pays for the administration of inhalation analgesia (nitrous oxide) as a separate procedure.

Not Medically Necessary The use of a hospital or a freestanding ambulatory surgery center due to lack of facilities for administering general anesthesia, when the procedure can be routinely performed with local anesthesia, is considered not medically necessary.

Coding Guidance

Code
Description
00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified 41899 Unlisted procedure, dentoalveolar structures

CPT® Copyright 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

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References

 MassHealth Dental Program Office Reference Manual Feb 28, 2023 https://www.masshealth-dental.net/MassHealth/media/Docs/MassHealth-ORM.pdf

 130 Mass. Reg 420.452

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/1/2023 Initial Policy Date

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. 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. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.