Number: 016
(Update)
Subject: Deep Sedation/General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services
Reviewed: February 19, 2020
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:
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.
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:
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.
According to guidelines from the American Academy of Pediatric Dentistry, the indications for deep sedation and general anesthesia in pediatric dental patients include:
D9222 - deep sedation/general anesthesia - first 15 minutes D9223 - deep sedation/general anesthesia – each subsequent 15 minutes D9239 - intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243 - intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minutes
See Medical Clinical Policy Bulletin:
General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services
Number: 0124
May 30, 2019: This CPB has been reviewed and maintained.
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; November 13, 2017; February 19, 2020
Revision Dates: September 24, 2003; September 13, 2004; August 10, 2007
1 American Dental Association. CDT 2020 Dental Procedure Codes:*
2 American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the American Dental Association House of Delegates October 2016. http://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/anesthesia_use_guidelines.pdf. Accessed February 19, 2020.
3 Parameters of Care: AAOMS Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare) Sixth Edition 2017.
*Copyright 2019 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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