General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services

Number: 0124

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses general anesthesia and monitored anesthesia care for oral and maxillofacial surgery and dental services.

1. Medical Necessity

   Note: Aetna covers medically necessary general anesthesia and monitored anesthesia care (MAC) for oromaxillofacial surgery (OMS) and dental-type services that are covered under the medical plan.  Aetna also covers general anesthesia and MAC in conjunction with dental or OMS services that are excluded under the medical plan when the criteria below are met.

   Aetna considers general anesthesia and MAC medically necessary for dental or OMS services if any of the following criteria is met:

   1. The member is a child, up to and including 12 years old, with a dental condition (such as baby bottle syndrome) that requires repairs of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions or any combinations of these noted or other dental procedures); or
   2. Members who exhibit 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 intellectual disability, cerebral palsy, epilepsy, cardiac problems and hyperactivity (verified by appropriate medical documentation); or
   3. Members who are extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative members with dental needs of such magnitude 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; or
   4. Members for whom local anesthesia is ineffective (such as due to acute infection, anatomic variations or allergy); or
   5. Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised; or
   6. Members with bony impacted wisdom teeth.

2. Policy Limitations and Exclusions

   Note: In general, coverage of medically necessary anesthesia services is available only in connection with underlying services that are covered under the medical benefits plan.  Please check your benefits plan to determine whether services are covered.  Note that most Aetna plans exclude coverage of cosmetic surgery.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
00170 - 00176	Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery
00190 - 00192	Anesthesia for procedures on facial bones or skull
21010 - 21030, 21034 - 21116, 21141 - 21268, 21275, 21295 - 21497	Incision, excision, introduction or removal, repair, revision, and/or reconstruction, and fracture and/or dislocation procedures of skull, facial bones and temporomandibular joint (except excision of torus mandibularis or maxillary torus palatinus, genioplasty, augmentation of mandibular body or angle, and reduction forehead, malar augmentation, medial canthopexy, or lateral canthopexy)
HCPCS (ADA/CDT-4) codes covered if selection criteria are met:
D9248	Nonintravenous conscious sedation
Other HCPCS Codes related to the CPB:
D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia
D9215	Local anesthesia in conjunction with operative or surgical procedures
G0330	Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room

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Background

According to guidelines from the American Academy of Pediatric Dentistry (AAPD, 2004 and 2005), 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. Patients who are extremely uncooperative, fearful, anxious including physically resistant children or adolescents 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.

The French National Authority for Health (Hittenger, 2005) stated that, for standard dental and oral procedures, local anesthesia should be preferred whenever possible.  Patients undergoing general anesthesia should have a pre-anesthesia consultation and informed of the potential risks of general anesthesia. Informed consent should be obtained from the patient or their legal representative. 

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References