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Health Coverage
Clinical Policy Bulletins
Dental - Clinical Policy Bulletins
Number: 016
Subject: Deep Sedation/General Anesthesia and I.V. Sedation for Oral and Maxillofacial Surgery and Dental Services Reviewed: August 10, 2007 Important Note This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary. We have reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas, and other relevant factors). We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information. Each benefits plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if there are any exclusions or other benefits limitations applicable to this service or supply. 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 (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members. Policy:
Note:In general, coverage of medically necessary anesthesia services is available only in connection with underlying services that are covered under the medical benefits plan. Please check your benefits plan to determine whether services are covered. Note that most Aetna plans exclude coverage of cosmetic surgery. Background: According to guidelines from the American Academy of Pediatric Dentistry, the indications for deep sedation and general anesthesia in pediatric dental patients include:
Codes1 CPT/HCPCS/ICD-9 Codes See Medical Clinical Policy Bulletin: Original Policy: Jan. 31, 1999 The above policy is based on the following references: 1American Dental Association. Current Dental Terminology, CDT-2007-2008: 67.*2American Medical Association. Current Procedural Terminology, CPT-2007: 35,336-337.** 3Practice Management Information Corporation. ICD-9 CM Millennium Edition-2004. Los Angeles CA Vol 1&2:170-491. 4American Academy of Pediatric Dentistry. General anesthesia. Patient Brochure. Chicago, IL: AAPD, 2005. http://www.aapd.org/publications/brochures/anesthesia.asp (accessed June 29, 2007). 5American Academy of Pediatric Dentistry. Guidelines for the elective use of conscious sedation, deep sedation and general anesthesia in pediatric dental patients. Adopted 1985: revised May 1998. Guidelines. In: AAPD Reference Manual 2004-2005. Chicago, IL: AAPD; 2004:74-80. 6American Academy of Pediatric Dentistry. Policy statement on the use of deep sedation and general anesthesia in the pediatric dental office. Adopted May 1999; revised 2004. Oral Health Policies. In: AAPD Reference Manual 2004-2005. Chicago, IL: AAPD; 2004:50-51. 7American Academy of Pediatric Dentistry (AAPD), Council on Clinical Affairs. Policy on third-party reimbursement of medical fees related to sedation/general anesthesia. Original policy May 1989, Revised May 2003. Oral Health Policies. In: AAPD Reference Manual 2004-2005. Chicago, IL: AAPD; 2004:55-56. 8AAOMS: Parameters and Pathways: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParPath 01); Version 3.0; Anesthesia in Outpatient Facilities; pages ANE/1 through ANE/23; copyright 2001 by the American Association of Oral and Maxillofacial Surgeons. 9American Association of Oral and Maxillofacial Surgeons. Position statement regarding anesthesia. Adopted December 2002, Larry Nissen, DDS, President of AAOMS 2002 - 2003. 10American Dental Association. Position statement regarding anesthesia. Adopted October 1999, American Dental Association House of Delegates 1999. * Copyright 2006 American Dental Association. All rights reserved. Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. |
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