National Medical Policy Subject:

General Anesthesia for Dental Procedures

Policy Number:

NMP533

Effective Date*:

June 2014

Updated:

June 2016 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document

For Medicaid Plans: Please refer to the appropriate State’s Medicaid manual(s), publication(s), citation(s), and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first:

Use

Reference/Website Link Source

X

National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other

Medicare Benefit Manual 100-02, Chpt 1, Section 70:

https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c01.p df Medicare Learning Network. ICN 903543 November 2013. Basic Medicare Resources for Health Care Professionals, Suppliers, and Providers. Intermediate Medicare Resources for Health Care Providers (855A). 2013: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNEdWebGuide/Downloads/Guided_Path ways_Provider_Specific_booklet.pdf

None

Use Health Net Policy

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Instructions  

 

Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.

Definitions (American Society of Anesthesiologists, 2009) Moderate Sedation/Analgesia (“Conscious Sedation”) is 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. Deep Sedation/Analgesia is 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 is 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.

Current Policy Statement NOTE: Facility services and/or deep sedation/general anesthesia provided in conjunction with dental treatment may be impacted by benefit plan language and governed by state mandates. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage Health Net, Inc. considers general anesthesia (GA), moderate and conscious/deep sedation (CS) or monitored anesthesia care (MAC) provided for dental services in a hospital or surgery center medical necessary for members who require the skilled services and monitoring provided in these facilities in order to ensure that health is not compromised. Any of the following criteria must be met: 1. The members is under 7 years of age; or 2. The member, regardless of age, has a developmental disorders such as mental retardation, autism spectrum or other pervasive developmental disorders 3. The member, regardless of age has a serious underlying medical condition; or. Examples of these conditions include:

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       

cerebral palsy epilepsy significant cardiac conditions such as recent MI, CHF, unstable angina, arrhythmias, cardiomyopathy significant blood disorders (e.g. anemia, hemophilia), poorly controlled diabetes conditions that may require intubation (e.g. enlarged tonsils, sleep apnea, decreased oropharyngeal patency [e.g. Ankylosis of temporomandibular joint]) advanced pulmonary disease (dependence on respirator or oxygen) History/family history of malignant hyperthermia

4. Members who are psychologically impaired (e.g. poorly controlled psychiatric disorders, dementia) or extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative or unable to follow commands; or 5. Members for whom local anesthesia is ineffective because of an acute infection, anatomic variations or allergy; or 6. Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised; or 7. Members who require extensive restorative or surgical procedures care.

Codes Related To This Policy NOTE:

The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.

Dental codes (may not be an all-inclusive list) ICD-9 Codes: 520.0-520.9 521.0-521.09 521.1-521.9 522.0-522.9 523.0-523.9 524.0-524.29 524.3-524.9 525.0-525.9 526.0-526.9

Diseases of tooth development and eruption Diseases of hard tissues of teeth Excessive attrition (proximal wear) (occlusal wear) Diseases of pulp and periapical tissues Gingival and periodontal diseases Dentofacial anomalies, including malocclusion Anomalies of tooth position of fully erupted teeth Other diseases and conditions of the teeth and supporting structures Diseases of the jaws

ICD -9 Codes General Condition Codes (may not be all inclusive) 277.5 280 - 289 250 290 - 294 295

Mucopolysaccharidosis Diseases Of The Blood And Blood-Forming Organs Uncontrolled Diabetes Organic Psychotic Conditions Schizophrenic disorders

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296 297 298 299 300 317 - 318 329 330 331 332 333 334 335 336 337 343.0 -343.9 345 410 -414 426 427 428 474 490-496 758.0-758.39 759.89 760.71 780.0 - 780.09

Episodic mood disorders Delusional disorders Other nonorganic psychoses Pervasive developmental disorders Anxiety, dissociative and somatoform disorders Other specified intellectual disabilities (Mental Retardation) Sleep apnea Cerebral degenerations usually manifest in childhood Other cerebral degenerations Parkinson's disease Other extrapyramidal disease and abnormal movement disorders Spinocerebellar disease Anterior horn cell disease Other diseases of spinal cord Disorders of the autonomic nervous system Infantile Cerebral Palsy Epilepsy Ischemic Heart Disease Conduction disorders Cardiac dysrhythmias Heart failure Hypertrophy of the tonsil/adenoids Chronic Obstructive Pulmonary Disease And Allied Conditions Chromosomal anomalies, Autosomal deletion anomalies Congenital anomalies, other specified anomalies Fetal Alcohol Syndrome Alteration of consciousness

ICD-10 Codes: Dental Codes: K00 K01 K02 K03 K04 K05 K06 K08 K09

Disorders of tooth development and eruption Embedded and impacted teeth Dental caries Other diseases of hard tissues of teeth Diseases of pulp and periapical tissues Gingivitis and periodontal diseases Other disorders of gingiva and edentulous alveolar ridge Other disorders of teeth and supporting structures Cysts of oral region, not elsewhere classified

ICD-10 Condition Codes (may not be all inclusive) E76 D50 – D89 E08-E13 F01-F09 F20 - F29 F30 – F39 F40 – F48

Mucopolysaccharidosis Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Uncontrolled Diabetes Mental disorders due to known physiological conditions Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders Mood Affective Disorders Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders

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F50 – F59 F60 – F69 F70 – F79 F80 – F89 F98 G10 G11 G12 G13 G20 – G21 G23 G24 –G25 G30 – G32 G35-G37 G40 G47.3 G80 G90 G95 I20 – I25 I26 – I28 I44 –I45 I47 – I49 I50 J35 J43 – J44 J45 J60 –J70 Q00 – Q07 Q10 - Q18 Q20 – Q28 Q30 – Q34 Q35 – Q37 Q38 – Q45 Q65 –Q79 Q80 – Q89 Q90 Q91 – Q92 Q93 – Q96 R40 - R46

Behavioral syndromes associated with physiological disturbances and physical factors Disorders of adult personality and behavior Intellectual disabilities (including mental retardation) Pervasive and specific developmental disorders (including autism)

Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence Huntington’s Disease Hereditary Ataxia (eg Spinocerebellar disease) Spinal Muscular Atrophy and related syndromes (eg Anterior horn cell disease) Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere Parkinson’s Disease Other degenerative diseases of basal ganglia Dystonia and Other extrapyramidal and movement disorders Alzheimer's disease and Other degenerative diseases of nervous system Demyelinating diseases of the central nervous system (eg multiple sclerosis Epilepsy Sleep apnea infantile Cerebral Palsy Chromosomal anomalies, Autosomal deletion anomalies Other and unspecified diseases of the spinal cord Ischemic Heart Disease Pulmonary Heart Disease and other diseases of pulmonary circulation Atrioventricular and left bundle-branch block and other conduction disorders Paroxysmal tachycardia, atrial fibrillation and flutter, other cardiac arrhythmias Heart Failure Chronic diseases of tonsils and adenoids Emphysema, COPD Asthma Lung diseases due to external agents Congenital malformations of the nervous system Congenital malformations of eye, ear, face and neck Congenital malformations of the circulatory system Congenital malformations of the respiratory system Cleft lip and cleft palate Other congenital malformations of the digestive system Congenital malformations and deformations of the musculoskeletal system Other congenital malformations (eg Fetal alcohol syndrome) Down Syndrome Trisomy 18 and Trisomy 13 and other trisomies, partial trisomies Other Chromosomal Abnormalities Symptoms and signs involving cognition, perception, emotional state and behavior

CPT Codes 5 General Anesthesia for Dental Procedures Jun 16

00170

Anesthesia for intraoral procedures, including biopsy; not otherwise specified

HCPCS Level II Code D9220 Deep sedation/general anesthesia; first 30 minutes (Code deleted 2016) D9221 Deep sedation/general anesthesia; each additional 15 minutes (Code deleted 2016)

2016 HCPCS Level II Code D9223

Deep sedation/general anesthesia; each 15 minute increment

Scientific Rationale - Initial Most dental procedures can be safely performed in a dental office setting with the use of premedication, local anesthesia, IV or non-IV conscious sedation. In limited situations, members may receive deep sedation anesthesia (general anesthesia) by a licensed anesthesiologist in a hospital or outpatient facility in limited situations as described in the policy statement. According to the American Academy of Pediatric Dentistry (AAPD), most dental care can be safely provided in a traditional dental office setting using local anesthesia, minimal sedation and other adjunctive pharmacologic and behavioral guidance techniques. However, in order to provide comprehensive dental care to patients with special needs such as acute situational anxiety, uncooperative age-appropriate behavior, immature cognitive functioning, developmental or physical disabilities, or certain medical conditions, deep sedation or general anesthesia performed in a hospital or surgery facility may be needed to ensure that necessary care is provided in an appropriate setting. According to guidelines from the American Academy of Pediatric Dentistry, 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

Review History June 2014 June 2015` June 2016

Medical Advisory Council, initial approval Update – no revisions. Updated codes. Update – no revisions. Updated codes.

This policy is based on the following evidence-based guidelines: N/A

References – Update June 2016 6 General Anesthesia for Dental Procedures Jun 16

1. 2.

Ettlin DA, Lukic N, Abazi J, et al. Tracking local anesthetic effects using a novel perceptual reference approach. J Neurophysiol. 2016 Mar 1;115(3):1730-4. doi: 10.1152/jn.00917.2015. Epub 2016 Jan 20. Lee JS, Graham R, Bassiur JP, et al. Evaluation of a Local Anesthesia Simulation Model with Dental Students as Novice Clinicians. J Dent Educ. 2015 Dec;79(12):1411-7.

References – Update June 2015 1. Keels MA. MA, Section on Oral Health, American Academy of Pediatrics. Management of dental trauma in a primary care setting. Pediatrics 2014; 133:e466. 2. McTigue DJ. Evaluation and management of dental injuries in children. UpToDate. Updated March 11, 2014.

References – Initial 1. American Academy of Pediatric Dentistry (AAPD). 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. 2. American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. Accessed June 14 at http://www.aapd.org/media/policies_guidelines/g_sedation.pdf 3. American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 2002; 96(4): 1004-17. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peerreviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.

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No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member’s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. The Policies do not replace or amend the Member’s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.

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