Medical Policy
Effective Date:01/01/2006 Title:Anesthesia & Facility Services for Dental Procedures
Revision Date:01/01/2020 Document:BI104:00
CPT Code(s):00170, D9222, D9223, D9239, D9240
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

This policy applies only to plans sold, modified or renewed on or after January 1, 2006.

1)    QualChoice will provide benefits for anesthesia and facilities for standard/routine (non-cosmetic) dental procedures which would ordinarily be done under local anesthesia provided that:

a)    The procedure is performed in a network hospital or a network ambulatory surgery facility, AND

b)    The situation meets medical necessity criteria, and the patient is:

i.      A child under 7 years of age who is determined by two (2) dentists to require without delay necessary dental treatment in a hospital or ambulatory surgical center for a significantly complex dental condition; OR

ii.    A person with a serious mental health condition that prevents use of local anesthesia for the procedure; OR

iii.   A person with a serious physical condition making hospital care necessary for the safe performance of dental work; OR

iv.   A person with a significant behavioral problem as (certified by a network physician) which precludes safe performance of the dental work under local anesthesia.

2)    Preauthorization is required.

3)    In no case will anesthesia for Orthognathic surgery or TMJ surgery be covered if the procedure itself is not covered.
Medical Statement

Preauthorization will be granted for the coverage of anesthesia and surgical facility charges under the following certain special conditions:

1)    The services must be provided in a network facility and the anesthesia done by a network anesthetist to get in-network benefits – if an out of network facility or out of network anesthesiologist is used, only out of network benefits will be payable, even with preauthorization; AND

2)    The treating dentist must certify that, because of the patient’s age or other circumstances, hospitalization and/or general anesthesia is required to perform the (non-cosmetic) dental work safely and effectively, AND

3)    The patient is subject to one of the following:

·         A child under 7 years of age; OR

·         The person has a serious mental health condition that prevents use of local anesthesia for the procedure; OR

·         The person has a serious physical condition making hospital care necessary for the safe performance of dental work; OR

·         The person has a significant behavioral problem as (certified by a network physician) which precludes safe performance of the dental work under local anesthesia; AND

4)    The surgery to be performed is not orthognathic or TMJ surgery.

Codes Used In This BI:

00170               Anesthesia for intra-oral procedures, including biopsy, NOS

D9222              Deep sedation/general anesthesia 1st 15 mins (new code 1/1/18)

D9223              Deep sedation/general anesthesia, subsequent 15 mins

D9239              IV moderate sedation/anesthesia 1st 15 mins (new code 1/1/18)                   

D9240              IV moderate sedation/anesthesia, subsequent 15 mins
Limits
Intentially left empty
Reference
Intentially left empty
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.