Latest Review Date: January 2024

Category:  Administrative                                                     

POLICY:

Anesthesia in the hospital or ambulatory surgery center (ASC) setting for dental or oral surgery procedures may be considered medically necessary for coverage including, but not limited to, the following circumstances:

• Children aged 8 or under;
• Neurobehavioral delays;
• Multiple procedures performed at the same session (e.g., extraction of six or more teeth);
• Complex procedures such as difficult extraction of impacted teeth;
• Conditions requiring intubation including but not limited to:
  • Sleep apnea;
  • Decreased oropharyngeal patency;
  • Enlarged tonsils;
  • Dental skeletal deformities such as mandibular hypoplasia;
  • Severe esophageal reflux
• Medical conditions:
  • Multiple system failures;
  • Significant cardiac arrhythmias (e.g., >5 premature ventricular contractions (PVC’s) per minute on electrocardiogram, sick sinus syndrome, etc.);
  • Poorly controlled diabetic or widely fluctuating blood sugars in spite of multiple insulin doses and vigorous attempts at control;
  • Presence of prosthetic valves and anticoagulation therapy;
  • Continuous need for anticoagulation therapy;
  • Presence of bleeding disorders such as hemophilia;
  • Myelodysplastic disease;
  • Significant history of sickle cell disease with multiple hospitalizations;
  • Documented latex allergy;
  • Advanced liver disease (e.g., cirrhosis with bleeding problems);
  • Acute or chronic renal failure needing multiple procedures or requiring difficult procedures;
  • Dementia, sequela of closed head trauma, or stroke causing inability to cooperate with directions;
  • Post-traumatic stress disorder requiring management with multiple medications;
  • Unstable or poorly controlled psychiatric disorders;
  • Conditions causing increased intracranial pressure;
  • Head and neck radiation;
  • Significant congestive heart failure (CHF) with limitations of normal activity and/or dyspnea;
  • Unstable angina;
  • Recent (within last six months) myocardial infarction (MI);
  • Epilepsy treated with one or more medications;
  • Advanced pulmonary disease (e.g. emphysema or bronchitis requiring supplemental oxygen therapy);
  • Neurological/neurosurgical conditions (e.g., aneurysm);
  • Untreated hyperthyroidism;
  • Severely compromised nutritional status.

Note: This policy addresses the medical criteria for coverage for anesthesia.  Even if the anesthesia meets medical criteria for coverage, the surgical procedure itself, may be considered dental by the member’s contract.

DESCRIPTION OF PROCEDURE OF SERVICE:

The administration of local anesthetic is common and used for most routine dental procedures. However, for some individuals, moderate/conscious sedation, non-intravenous sedation and deep sedation/general anesthesia may be necessary to safely provide dental care. These procedures generally are safe when administered by trained, certified providers in the appropriate setting, but are not without risk. According to the American Dental Association (ADA), dentists must comply with their state laws, rules and/or regulations when providing sedation and anesthesia and follow the educational and training requirements for the level of sedation intended. The ADA maintains clinical guidelines and educational/training requirements for all levels of sedation and includes specific information for the following:

• Patient history and evaluation
• Personnel and equipment requirements
• Monitoring and documentation (including consciousness, oxygenation, ventilation, and circulation)
• Recovery and discharge
• Emergency management

Sedation and analgesia comprise a continuum of states ranging from minimal sedation through general anesthesia. Definitions of levels of sedation–analgesia, as developed by the American Society of Anesthesiologists (ASA):

• Minimal Sedation (Anxiolysis) = a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
• Moderate Sedation/Analgesia (Conscious Sedation) = a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

*Monitored Anesthesia Care (“MAC”) does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.” Indications for monitored anesthesia care include "the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic."

** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

• Deep Sedation/Analgesia = a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
• General Anesthesia = a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
  • Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedation) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of general anesthesia.

** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

*** Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.

Monitoring of patient response to verbal commands should be routine during moderate sedation, except in patients who are unable to respond appropriately (e.g., young children, mentally impaired or uncooperative patients), or during procedures where movement could be detrimental. During deep sedation, patient responsiveness to a more profound stimulus should be sought, unless contraindicated, to ensure that the patient has not drifted into a state of general anesthesia. Note that a response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia.

All patients undergoing sedation/analgesia should be monitored by pulse oximetry with appropriate alarms. In addition, ventilatory function should be continually monitored by observation or auscultation. Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation. When possible, blood pressure should be determined before sedation/analgesia is initiated. Once sedation–analgesia is established, blood pressure should be measured at intervals during the procedure. Electrocardiographic monitoring should be used in all patients undergoing deep sedation. It should also be used during moderate sedation in patients with significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated.

A designated individual, other than the practitioner performing the procedure, should be present to monitor the patient throughout procedures performed with sedation/analgesia. During deep sedation, this individual should have no other responsibilities. However, during moderate sedation, this individual may assist with minor, interruptible tasks once the patient’s level of sedation–analgesia and vital signs have stabilized, provided that adequate monitoring for the patient’s level of sedation is maintained.

KEY POINTS:

The most recent literature update was performed through January 2024.

SUMMARY OF EVIDENCE:

Monitored anesthesia care may include varying levels of sedation, analgesia and anxiolysis as necessary. The qualified anesthesiologist provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of procedure and position in the management in induction of general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

PRACTICE GUIDELINES AND POSITION STATEMENTS:

American Society of Anesthesiologists (ASA)

The American Society of Anesthesiologists (ASA) has defined four levels of sedation: minimal, moderate, deep, and general. These levels are defined by four physiologic responses: responsiveness, airway, spontaneous ventilation, and cardiovascular function.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Anesthesia, monitored anesthesia care, MAC, conscious sedation, oral surgery

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

CPT codes may include, but are not limited to the following:

REFERENCES:

1. American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. Chicago: ADA House of Delegates; 2012.
2. American Dental Association. 2012 Policy Statement:  The use of sedation and general anesthesia by dentists. http://www.ada.org/en/~/media/ADA/Advocacy/Files/anes_policy_statement.
3. American Dental Association. 2016 Guidelines:  The use of sedation and general anesthesia by dentists. http://www.ada.org/en/~/media/ADA/Education%20and%20Careers/Files/ADA_Sedation_Use_Guidelines.
4. 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.
5. American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by Dentists. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements.
6. American Society of Anesthesiologists. Position on Monitored Anesthesia Care. 2016.
7. American Academy of Pediatric Dentistry. Policy on the use of deep sedation and general anesthesia in the paediatric dental office. Chicago: American Association of Pediatric Dentistry; 2012.
8. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. www.asahq.org/quality-and-practice-management/standards-and-guidelines.
9. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists.  Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96(4): 1004-17.
10. British Society for Disability and Oral Health. The Provision of Oral Health Care under General Anaesthesia in Special Care Dentistry: A Professional Consensus Statement. British Society for Disability and Oral Health; 2009.
11. Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. 2019 Pediatr Dent 2019;41(4):E26-E52.
12. de Nova-García MJ, Gallardo López NE, Martín Sanjuán C, et al. Criteria for selecting children with special needs for dental treatment under general anesthesia. Med Oral Patol Oral Cir Bucal. 2007 Nov 1;12(7):E496-503.
13. Kim A, Ved S. ASA Sedation Guidelines for Non-Anesthesiologists. In: Freeman BS, Berger JS. eds. Anesthesiology Core Review: Part One Basic Exam. McGraw Hill; 2014. https://accessanesthesiology.mhmedical.com/content.aspx?bookid=974&sectionid=61588787
14. Lehtonen V, Sándor GK, Ylikontiola LP, et al. Dental treatment need and dental general anesthetics among preschool-age children with cleft lip and palate in northern Finland. Eur J Oral Sci. 2015 Aug;123(4):254-9.
15. Lim MAWT, Borromeo GL. The use of general anesthesia to facilitate dental treatment in adult patients with special needs. J Dent Anesth Pain Med. 2017 Jun;17(2):91-103. doi: 10.17245/jdapm.2017.17.2.91. Epub 2017 Jun 29.
16. Loyola-Rodriguez JP, Aguilera-Morelos AA, Santos-Diaz MA, Zavala-Alonso V, Davila-Perez C, Olvera-Delgado H, et al. Oral rehabilitation under dental general anesthesia, conscious sedation, and conventional techniques in patients affected by cerebral palsy. J Clin Pediatr Dent. 2004;28:279–284.
17. Nelson TM, Xu Z. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent. 2015 Aug 26;7:97-106.
18. Parameters of Care: AAOMS Clinical Practice Guidelines for Oral and Maxofacial Surgery (AAOMS ParCare) Sixth Edition 2017.
19. Ross AK.  Office-based anesthesia for children.  Anesthesiol Clin North America 2002; 20(1): 195-210.
20. Southerland JH, Brown LR. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Dent Clin North Am. 2016 Apr;60(2):309-46.

POLICY HISTORY:

Medical Policy Group, July 2005 (2)

Medical Policy Group, November 2005 (2)

Medical Policy Administration Committee, November 2005

Available for comment November 3-December 17, 2005

Medical Policy Group, July 2006 (2)

Medical Policy Group, July 2009 (1)

Medical Policy Group, August 2012 (1)

Medical Policy Group, August 2014 (1)

Medical Policy Group, August 2016 (1)

Medical Policy Group, August 2017 (1)

Medical Policy Group, February 2020 (6): Updates to Description, Key Points and References. No change in policy intent.

Medical Policy Group, January 2021 (6): Updates to Description, Key Points, Coding and References. No change to policy intent.

Medical Policy Group, March 2021 (6): Reviewed by consensus. Updates to Key Points. No change in policy intent.

Medical Policy Group, April 2022 (6): Updates to Key Points. No change to policy intent.

Medical Policy Group, January 2023 (6): Updates to Key Points.

Medical Policy Group, January 2024 (6): Updates to Key Points, USPSTF, Practice Guidelines, Benefit Application and References.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.