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Clinical Policy Bulletin:
General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services
Number: 0124


Note: Aetna covers medically necessary general anesthesia and monitored anesthesia care (MAC) for oromaxillofacial surgery (OMS) and dental-type services that are covered under the medical plan.  Aetna also covers general anesthesia and MAC in conjunction with dental or OMS services that are excluded under the medical plan when the criteria below are met.

Aetna considers general anesthesia and MAC medically necessary for dental or OMS services if any of the following criteria is met:

  1. The member is a child, up to 6 years old, with a dental condition (such as baby bottle syndrome) 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); or
  2. Members who exhibit physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and which, under anesthesia, can be expected to produce a superior result.  Conditions include but are not limited to mental retardation, cerebral palsy, epilepsy, cardiac problems and hyperactivity (verified by appropriate medical documentation); or
  3. Members who are extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative members with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity; or
  4. Members for whom local anesthesia is ineffective (such as due to acute infection, anatomic variations or allergy); or
  5. Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised; or
  6. Members with bony impacted wisdom teeth.

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.


According to guidelines from the American Academy of Pediatric Dentistry (AAPD, 2004 and 2005), the indications for deep sedation and general anesthesia in pediatric dental patients include:

  1. Patients with certain physical, mental or medically compromising conditions;
  2. Patients with dental restorative or surgical needs for whom local anesthesia is ineffective;
  3. Patients who are extremely uncooperative, fearful, anxious including physically resistant children or adolescents with substantial dental needs and no expectation that the behavior will improve soon;
  4. Patients who have sustained extensive orofacial or dental trauma;
  5. Patients with dental needs who otherwise would not receive comprehensive dental care.

The French National Authority for Health (Hittenger, 2005) stated that, for standard dental and oral procedures, local anesthesia should be preferred whenever possible.  Patients undergoing general anesthesia should have a pre-anesthesia consultation and informed of the potential risks of general anesthesia. Informed consent should be obtained from the patient or their legal representative.  

CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
00170 - 00176
00190 - 00192
21010 - 21030, 21034 - 21116, 21141 - 21268, 21275, 21295 - 21497
HCPCS (ADA/CDT-4) codes covered if selection criteria are met:
D9220 Deep sedation/general anesthesia, first 30 minutes
D9221 Deep sedation/general anesthesia, each additional 15 minutes
D9241 Intravenous conscious sedation/analgesia - first 30 minutes
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes
D9248 Nonintravenous conscious sedation
Other HCPCS Codes related to the CPB:
D9210 Local anesthesia not in conjunction with operative or surgical procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia in conjunction with operative or surgical procedures
Other ICD-9 Codes related to the CPB:
143.0 - 143.9 Malignant neoplasm of gum
170.0, 170.1 Malignant neoplasm of bones of skull and face, except mandible, or malignant neoplasm of mandible
195.0 Malignant neoplasm of head, face, and neck
210.4 Benign neoplasm of other and unspecified parts of mouth
213.0, 213.1 Benign neoplasm of bones of skull and face, or lower jaw bone
308.0 Predominant disturbance of emotions
308.3 Other acute reaction to stress
314.01 Attention deficit disorder with hyperactivity
317 - 319 Mental retardation
343.0 - 343.9 Infantile cerebral palsy
345.00 - 345.91 Epilepsy and recurrent seizures
520.0 - 525.9 Disorders of tooth development and eruption, diseases of hard tissues of teeth, diseases of pulp and periapical tissues, gingival and periodontal diseases, dentofacial anomalies, including malocclusion, and other diseases and conditions of teeth and supporting structures
526.0 - 526.89 Diseases of jaws
744.81 - 744.9 Other and unspecified anomalies of face and neck
756.0 Anomalies of skull and face bones
758.0 Down's syndrome
780.33 Post traumatic seizures
780.39 Convulsions
802.0 - 802.9 Fracture of face bones
830.0 - 830.1 Dislocation of jaw
910.0 - 910.9 Superficial injury of face, neck, and scalp except eye
959.01 - 959.09 Injury, other and unspecified of head face and neck

The above policy is based on the following references:
  1. American Academy of Pediatric Dentistry (AAPD). General anesthesia. Patient Brochure. Chicago, IL: AAPD; 2005. Available at: Accessed July 8, 2005.
  2. American Academy of Pediatric Dentistry (AAPD). 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.
  3. American Academy of Pediatric Dentistry (AAPD). 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.
  4. American 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 2003. Oral Health Policies. In: AAPD Reference Manual 2004-2005. Chicago, IL: AAPD; 2004:55-56.
  5. Hittinger MC. Indications for general anaesthesia for standard dental and oral procedures. Abstract. Saint-Denis La Plaine, France: Haute Autorite de Sante (French National Authority for Health) (HAS); 2005. Available at: Accessed February 21, 2012.
  6. Matharu LL, Ashley PF. Sedation of anxious children undergoing dental treatment. Cochrane Database Syst Rev. 2006;(1):CD003788.
  7. Matharu LL, Ashley PF. What is the evidence for paediatric dental sedation? J Dentistry. 2007;35(1):2-20.

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This 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 providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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