Subject: Deep Sedation/General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services
Reviewed: December 8, 2014
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:
D9220 - deep sedation/general anesthesia - first 30 minutes
D9221 - deep sedation/general anesthesia - each additional 15 minutes
D9241 - intravenous moderate (conscious) sedation/analgesia - first 30 minutes
D9242 - intravenous moderate (conscious) sedation/analgesia - each additional 15 minutes
D9248 - non-intravenous moderate (conscious) sedation
See Medical Clinical Policy Bulletin:
General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services
For CPT Codes / HCPCS Codes / ICD-9 Codes
Place of service: Inpatient or outpatient
Original Policy: January 31, 1999
Updated: January 09, 2009; February 22, 2010; May 23, 2011; September 10, 2012; November 5, 2013; December 8, 2014
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 2014 Dental Procedure Codes: 85-87.**
2 American Dental Association. CDT 2015 Dental Procedure Codes: 83-84.***
3 Practice Management Information Corporation.ICD-9 CM Millennium Edition-2004. Los Angeles CA Vol 1&2:170-491.
4 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).
5 American 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.
6 American 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.
7 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 May 2003. Oral Health Policies. In: AAPD Reference Manual 2004-2005. Chicago, IL: AAPD; 2004:55-56.
8 AAOMS: 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.
9 American Association of Oral and Maxillofacial Surgeons. Position statement regarding anesthesia. Adopted December 2002, Larry Nissen, DDS, President of AAOMS 2002 - 2003.
10 American 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 2013 American Dental Association. All rights reserved.
***Copyright 2014 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.