Sunflower Health Plan IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) Form

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 I. It is the policy of health plans affiliated with Centene Corporation® that intravenous moderate sedation, intravenous deep sedation, and general anesthesia are medically necessary when all of the following general criteria and place of service-specific criteria are met in either II or III: A. One or more of the following indications: 1. Documented extreme anxiety or fear and documentation of failed local anesthesia, inhalation of nitrous oxide, or oral conscious sedation attempts; 2. Dental and medical records documentation substantiates a physical, cognitive, or developmental disability (including, but not limited to, congenital cardiac defect, cerebral palsy, epilepsy) that would render the patient non-compliant; 3. Underlying medical conditions are supported by patient records; 4. There is documentation of allergy or sensitivity to local anesthesia; 5. Lengthy and numerous (more than four) restorative procedures for pediatric member/enrollee; 6. Documentation indicates a pediatric member/enrollee has resisted all other conventional behavior management procedures; 7. Documentation indicates a pediatric member/enrollee has history of uncooperative behaviors that may result in the compromised safety of the member/enrollee, provider, or staff; 8. Documented history of relevant social impact conditions; 9. Complex and extensive surgical procedures such as two or more impacted teeth in two or more quadrants, or two or more extractions of permanent teeth per quadrant in at least two quadrants. B. None of the following: 1. Member/enrollee has predisposing medical and/or physical conditions that would make general anesthesia unsafe; Page 1 of 9 CLINICAL POLICY IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures 2. Member/enrollee is cooperative and has minimal dental needs; 3. General anesthesia or moderate or deep sedation is requested for member/enrollee or dentist convenience; 4. Member/enrollee has history of tolerating similar dental procedures without the need for sedation; 5. Member/enrollee has a choice of an alternative option for treatment; 6. Member/enrollee has an allergy to oral sedatives or reversal agents; 7. Parent or guardian objects to the sedation or general anesthesia; 8. There are no covered and approved dental services to be rendered. C. Required documentation, all the following: 1. Current (less than six months) diagnostic quality pre-operative radiographs (when achievable) or intraoral photographic images if radiographs are not achievable or if requested treatment is not visualized in the radiographs; 2. Patient chart and treatment notes document conditions supporting medical necessity and all relevant dental and medical diagnoses and/or ICD-10 diagnosis codes; 3. Patient chart and treatment notes document applicable non-clinical and/or relevant social conditions; 4. Complete treatment plan; 5. ASA physical status classification (ASA Classes III and IV for member/enrollees under the age of eight will not be approved for a dental office setting); 6. Specific history of failed anesthesia, sedation, or analgesia/anxiolysis attempts; 7. Referring dentist evaluation records; 8. State-mandated outpatient (OP) form, if applicable. 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 Page 2 of 9 CLINICAL POLICY IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures 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 recommendations5. Page 3 of 9 CLINICAL POLICY IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures • • • • • • 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 • Nitrous oxide and oxygen Oral Conscious Sedation • Midazolam – Schedule IV • • Hydroxyzine Diphenhydramine IV Moderate Sedation • Benzodiazapine • Opioids – Schedule II IV Deep Sedation/General Anesthesia • • • • • • • • • • Propofol Benzodiazapine Ketamine – Schedule III Dexmedetomide Sevoflurane Desflurane Isoflurane 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. Page 4 of 9 CLINICAL POLICY IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures 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 2022, 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 2022, 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 00170 00190 Anesthesia for intraoral procedures, including biopsy; not otherwise specified Anesthesia for procedures on facial bones or skull; not otherwise specified Page 5 of 9 CLINICAL POLICY IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures CDT® Codes D9222 D9223 D9239 D9243 D9248 Deep sedation/general anesthesia – first 15 minutes Deep sedation/general anesthesia – each subsequent 15-minute increment Intravenous moderate (conscious) sedation/analgesia – first 15 minutes Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment Non-intravenous conscious sedation Reviews, Revisions, and Approvals Policy developed References reviewed and updated. Specialist reviewed. References reviewed and updated Annual review. References reviewed and updated. Replaced all instances of member with member/enrollee. Specialist reviewed. 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.” Changed title from “Dental Anesthesia” to “IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures” and adopted the Envolve Dental Policy criteria from ENVD.UM.CP.0009, approved 11/21. Removed HCPCS code D9230. Minor rewording without 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. 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. Revision Date 03/19 03/20 02/21 Approval Date 06/13 04/19 03/20 03/21 10/21 10/21 10/22 10/22 10/23 10/23