Pediatric Dental Anesthesia

POLICY NUMBER

L.7.02.402

DESCRIPTION

Pediatric dental patients may require special care for the reduction of anxiety and fear, as well as the management of pain. Dental assessment includes evaluation of the child’s age, developmental and cognitive level, temperament and personality characteristics, general anxiety and fear, reaction to strangers, previous dental experiences, and the dental anxiety of the parents. Children under the age of 4 may be more sensitive to pain and are unable to communicate as well as older children. The presence of acute or chronic disease also influences the dental experience.

The American Academy of Pediatric Dentistry states that dentists who treat children should have a variety of approaches to address and guide the behavior of a child. These techniques include “tell-show-do,” voice control of staff members, nonverbal communication, headphones, positive reinforcement, distraction and parental presence or absence. The administration of nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and include a variable degree of analgesia and amnesia, as well as reducing the gag reflex.

Most children can be managed effectively using these techniques, and so these basic techniques should be considered the foundation of all management provided by the dentist. However, if a child cannot cooperate due to psychological or emotional immaturity and/or mental, physical or medical disability, sedation or general anesthesia may be necessary.

POLICY

General anesthesia and associated facility charges may be considered medically necessary to provide dental care to pediatric patients when the following criteria are met:

1. Performed in an outpatient hospital or outpatient surgery center, AND

2. Patient is age 6 and under, AND

3. Patient has significant dental disease of 6 or more teeth (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

4. Patient has a physical, intellectual, or medically compromising condition, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result. Conditions include, but are not limited to: Down syndrome, autism, quadriplegic, cerebral palsy, epilepsy, cardiac problems, asthma, bleeding disorder (verified by appropriate medical documentation).

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Member, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

08/01/2020: New policy added.

01/18/2023: Policy reviewed. Policy statement unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

02/14/2024: Policy reviewed; no changes.

03/13/2025: Policy reviewed; no changes.

01/01/2026: Code Reference section updated to add new CPT codes D9224 and D9225.

SOURCE(S)

1. Aetna General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services Medical Policy

2. UCare Pediatric Dental Anesthesia Medical Policy.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

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