Number: 016
(Update)

Subject: Deep Sedation/General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services

Reviewed:  February 17, 2016

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on 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
• 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 refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee 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: Aetna covers medically necessary general anesthesia or IV sedation for oromaxillofacial surgery (OMS) and dental-type services that are covered under the medical plan. Aetna also covers general anesthesia or IV sedation in conjunction with dental or OMS services that are excluded under the medical plan when the criteria below are met.

Aetna considers general anesthesia or IV sedation 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 (for example, multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions or any combinations of these noted or other dental procedures)
2. The member has 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)
3. This member is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative with dental needs so serious 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
4. Members for whom local anesthesia is ineffective (for reasons such as acute infection, anatomic variations or allergy)
5. Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised

Note: In general, coverage of medically necessary anesthesia services or IV sedation is available only in connection with underlying services that are covered under the benefits plan. Please check your benefits plan to determine whether services are covered. Note that most Aetna plans do not cover 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:

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. The extremely uncooperative, fearful, anxious or physically resistant child or adolescent 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

Codes¹

D9223 - deep sedation/general anesthesia – each 15 minute increment 
D9243 - intravenous moderate (conscious) sedation/analgesia – each 15 minute increment 
D9248 - non-intravenous moderate conscious sedation

CPT/HCPCS/ICD-9 Codes*

See Medical Clinical Policy Bulletin:
General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services
Number:  0124
For CPT Codes / HCPCS Codes / ICD-9 Codes

Place of service: Inpatient or outpatient

Revision Dates:

Original Policy: January 31, 1999
Updated: January 09, 2009; February 22, 2010; May 23, 2011; September 10, 2012; November 5, 2013; December 8, 2014; February 17, 2016
Revision Dates: September 24, 2003; September 13, 2004; August 10, 2007

The above policy is based on the following references:

¹ American Dental Association. CDT 2016 Dental Procedure Codes: 85-86.**

² Practice Management Information Corporation.ICD-9 CM Millennium Edition-2004. Los Angeles CA Vol 1&2:170-491.

³ American Academy of Pediatric Dentistry. General anesthesia. Patient Brochure. Chicago, IL: AAPD, 2005. http://digital.ipcprintservices.com/publication/?m=17246&l=1 (accessed April 30, 2014).

⁴American 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.

⁵American 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.

⁶American 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.

⁷AAOMS: 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.

⁸American Association of Oral and Maxillofacial Surgeons. Position statement regarding anesthesia. Adopted December 2002, Larry Nissen, DDS, President of AAOMS 2002 - 2003.

⁹American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the American Dental Association House of Delegates 2007. Accessed December1, 2014 from http://www.ada.org/~/media/ADA/Member%20Center/Files/anesthesia_guidelines.ashx        

*Copyright 2012 American Medical Association. All rights reserved.

**Copyright 2015 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.