News
Medical Necessity Criteria: Dental Anesthesia
Date: 07/07/16
General anesthesia allows for the safe and humane provision of dental diagnostic and surgically invasive procedures for a small subset of members. Those included in this subset are children who may be cognitively immature, highly anxious or fearful, have special needs, or are medically-compromised and unable to receive treatment in a traditional office setting.
California Health & Wellness (CH&W) covers medically necessary services administered in connection with dental services that are not provided by dentists or dental anesthesiologists. Providers must be qualified and appropriately trained individuals in accordance with state regulations and professional society guidelines. All locations that administer general anesthesia must be equipped with anesthesia emergency drugs, appropriate resuscitation equipment, and properly trained staff to skillfully respond to anesthetic emergencies.
Members may receive treatment for a dental procedure provided under general anesthesia or IV sedation by a physician anesthesiologist in a hospital, accredited ambulatory surgical center (stand-alone facility); or a Federally Services are considered medically necessary when either A or B are met:
A. Behavior modification and local anesthesia failed or are not possible. This requires documentation in the clinical records of both:
1. Failure of local anesthesia to control pain, and
2. Failure of conscious sedation, either inhalation or oral.
B. Documentation in the clinical record of any one of the following:
1. An approved Denti-Cal TAR for the requested services.
2. Failure of effective communicative techniques and the inability for immobilization (patient may be dangerous to self or staff).
3. Member requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or conscious sedation.
4. Member has acute situational anxiety due to immature cognitive functioning.
5. Member is uncooperative due to certain physical or mental compromising conditions.
6. Member exhibits physical, intellectual, or medically-compromised conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a humane and successful result and which, under general anesthesia, can be expected to produce a superior result.
7. Member needs local anesthesia with dental treatment, but the local anesthesia is/will be ineffective because of acute infection, anatomic variation or allergy.
8. Member is extremely uncooperative, fearful, anxious or uncommunicative with dental needs of such magnitude or clinically apparent and functionally threatening to the well-being of the individual that treatment should not be postponed or deferred and the 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 mortality.
9. Member has sustained oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised.
Patients with certain medical conditions, such as moderate to severe asthma, reactive airway disease, congestive heart failure, cardiac arrhythmias, and significant bleeding disorders (continuous Coumadin therapy) should be treated in a hospital setting or a licensed facility capable of responding to a serious medical crisis.
Authorization for general anesthesia provided by a physician anesthesiologist to a beneficiary during an inpatient stay must be part of the authorization for the inpatient admission. Authorization is not required prior to delivering intravenous sedation or general anesthesia as part of an outpatient dental procedure in a state certified skilled nursing facility (SNF) or any category of intermediate care facility (ICF) for the developmentally disabled.
The California Health & Wellness policy for Dental Anesthesia can be found on the Provider Resources page on our website (from the home page, click on the “For Providers” tab and select “Provider Resources” from the pull-down menu. The policy is located in the “More Resource Topics” section.