Clinical UM Guideline

 

 

Subject: Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Guideline #:  CG-MED-41 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018

Description

This document addresses the use of moderate to deep anesthesia services utilized in the facility setting when used to treat individuals undergoing dental procedures. This excludes the office setting.

Note: Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

The use of moderate to deep anesthesia services during the delivery of dental services is considered medically necessary when submitted documentation (including narrative, radiographs, etc.) demonstrates the presence of any of the following circumstances:

  1. Children (up to 20 years of age) requiring extensive operative procedures (such as multiple restorations, treatment of abscesses or oral surgical procedures), when in-office treatment (nitrous oxide or IV sedation) is not appropriate and hospitalization is not solely based upon reducing, avoiding or controlling apprehension; or
  2. Individuals requiring extensive dental procedures and classified by the American Society of Anesthesiologists (ASA) as class 3 or class 4; or
  3. Individuals requiring extensive dental procedures and classified with a Mallampati score of 3 or 4; or
  4. Medically compromised patients whose medical history indicates that the monitoring of vital signs or the availability of resuscitative equipment is necessary during dental procedures; or
  5. Individuals requiring extensive dental procedures with a medical history of uncontrolled bleeding, severe cerebral palsy or other medical condition that renders in-office treatment not medically appropriate; or
  6. Individuals requiring extensive dental procedures who have documentation of significant behavioral health conditions or psychiatric disorders that require special treatment (for example, severe panic disorder); or
  7. Cognitively disabled individuals requiring extensive procedures whose prior history indicates hospitalization is appropriate; or
  8. Hospitalized individuals who need extensive restorative or surgical procedures.

Not Medically Necessary:

The use of moderate to deep anesthesia services during the delivery of dental services is considered not medically necessary when the above criteria have not been met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

00170

Anesthesia for intraoral procedures, including biopsy; not otherwise specified

99151

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

99152

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

99153

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time

99155

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age

99156

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older

99157

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time

 

 

 

CPT Physical Status Modifiers

P1

A normal healthy patient (Class I)

P2

A patient with mild systemic disease (Class II)

P3

A patient with severe systemic disease (Class III)

P4

A patient with severe systemic disease that is a constant threat to life (Class IV)

 

 

HCPCS

 

D9220-D9221

Deep sedation/general anesthesia

 

 

ICD-10 Diagnosis

 

K00.0-K00.9

Disorders of tooth development and eruption [includes codes K00.0, K00.1, K00.2, K00.3, K00.4, K00.5, K00.6, K00.7, K00.8, K00.9]

K01.0-K01.1

Embedded and impacted teeth

K02.3-K02.9

Dental caries [includes codes K02.3, K02.51, K02.52, K02.53, K02.61, K02.62, K02.63, K02.7, K02.9]

K03.0-K03.9

Other diseases of hard tissues of teeth [includes codes K03.0, K03.1, K03.2, K03.3, K03.4, K03.5, K03.6, K03.7, K03.81, K03.89, K03.9]

K04.0-K04.99

Diseases of pulp and periapical tissues [includes codes K04.01-K04.02, K04.1, K04.2, K04.3, K04.4, K04.5, K04.6, K04.7, K04.8, K04.90, K04.99]

K05.00-K06.9

Gingivitis and periodontal diseases [includes codes K05.00, K05.01, K05.10, K05.11, K05.20, K05.211-K05.219, K05.221-K05.229, K05.30, K05.311-K05.319, K05.321-K05.329, K05.4, K05.5, K05.6, K06.010-K06.023, K06.1, K06.2, K06.3, K06.8, K06.9]

K08.0-K08.119

Other disorders of teeth and supporting structures [includes codes K08.0, K08.101, K08.102, K08.103, K08.104, K08.109, K08.111, K08.112, K08.113, K08.114, K08.119]

M26.70-M26.79

Dental alveolar anomalies [includes codes M26.70, M26.71, M26.72, M26.73, M26.74, M26.79]

M26.81-M26.82

Soft tissue impingement; anterior or posterior

Discussion/General Information

The selection of where to conduct dental procedures is based on a wide variety of factors, including the health of the individual and the type of procedure proposed. These factors will significantly impact the type of anesthesia used during the procedure. Usually for routine and simple procedures in healthy individuals, the dental or oral surgeon’s office is an appropriate site. Alternatively, for complex procedures or for unhealthy individuals, a hospital operating room may be appropriate. For many individuals and procedures, other places of service, such as outpatient surgery centers, may be appropriate. This is because the risk of surgical and anesthesia complications increases with decreasing health of the individual and an increasing level of procedural complexity. As the risk of complications increases, so does the need for the appropriate equipment, personnel and other resources to deal with them should they occur. Higher level facilities such as outpatient surgical centers are more able to deal with adverse events because they are properly equipped with trained personnel and the tools and medications which may be required.

The goal of anesthesia during dental procedures, including tooth extractions and reconstructions, is intended to control and mitigate the incidence of pain, fear, and anxiety during the procedure. There is a wide variety of medications available that can be used to meet these goals, each with its own benefits and risks. These medications range from local anesthetics to numb the anatomic area being addressed to full general anesthesia that places the individual unconscious and immobilized. The selection of the appropriate medications to be used in any given situation is based on many factors, including the health and mental state of the individual as well as the extent of the proposed procedure. Generally, the more complex the procedure the more sedation and pain control needed, and the stronger medications that are required. This needs to be balanced with the frequently not-insignificant risks posed by the more powerful medications due to their interactions with various health conditions which may be adversely affected by their use. Conversely, some individuals with serious health conditions may require stronger medications than healthier individuals to allow doctors to conduct necessary procedures in a safe and effective manner.

One tool commonly used as a guide in the decision making process is the American Society of Anesthesiologists (ASA) Physical Status Classification System. This system is used to evaluate the overall health of the individual to identify his or her risk of complications during surgery, and to assist in identifying system-specific health conditions that may require tailored anesthetic regimens to avoid complications and provide the most appropriate care. The ASA classification system is as follows, and is derived by a thorough evaluation of an individual’s overall health as assessed by a healthcare provider’s review of an individual’s health, family history, medications used, diet, and other factors:

Another tool used by anesthesiologists and other medical providers concerned with upper airway management is the Mallampati score. This score is used to assess oropharyngeal anatomy by gauging the visibility of structures in the oral pharynx, and is used to estimate the difficulty in maintaining upper airway in the event breathing is compromised during medical procedures. The score ranges from complete visualization, including the tonsillar pillars (class I), to no visualization at all, with the tongue pressed against the hard palate (class IV). Class I and Class II predict adequate oral access, Class III predicts moderate difficulty, and Class IV predicts a high degree of difficulty (Mallampati, 1985; Sherwood, 2012). The full scoring schema is below:

Class 1: Visualization of the soft palate, fauces, uvula, and anterior and posterior pillars.
Class 2: Visualization of the soft palate, fauces, and uvula.
Class 3: Visualization of the soft palate and the base of the uvula.
Class 4: Soft palate not visible at all.

The ASA document “Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia” (2014) provides clear definitions for Moderate and Deep sedation:

In 2016 the American Dental Association released a policy statement titled, The Use of Sedation and General Anesthesia by Dentists. In this document they stated that moderate sedation was appropriate for individuals with ASA III and IV, and obesity, especially when associated with airway associated morbidity. They also stated that deep sedation or general anesthesia may be appropriate for mentally or physically challenged individuals.

The American Academy of Pediatric Dentistry (AAPD) published their Guideline on Behavior Guidance for the Pediatric Dental Patient in 2016. This document provided the following recommendations:

General anesthesia is indicated for:

Contraindications: The use of general anesthesia is contraindicated for:

The American Association of Oral and Maxillofacial Surgeons (AAOMS) published the Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery for Patient Assessment and Anesthesia in Outpatient Facilities (2012). These documents provide guidance for the selection of anesthetic regimens during oral and maxillofacial surgery as well as a specific guide for the evaluation of individuals undergoing various types of anesthetic regimens. They identify three specific populations of individuals at higher risk of complications due to anesthesia delivery, including pregnant women, children, and those with obesity. These populations present with a significantly higher risk of anesthesia and surgical complications due to physiological and anatomical variations that may affect drug metabolism, access to the upper airway, or in the case of pregnancy, exposure to drugs with poorly studied effects on the fetus. The AAOMS also identifies many health conditions that may impact or be impacted by anesthesia, including asthma, diabetes, cardiac disease, hematologic diseases, and familial risk for malignant hyperthermia. The more powerful drugs in the anesthetic armamentarium may have significant impact on a wide variety of physiologic systems including respiration, heart function and glucose metabolism, which in compromised individuals may temporarily alter the function of the body and increase the risk of adverse events. Identifying individuals with specific health conditions that create susceptibility to complications allows health care providers to choose the most appropriate anesthesia regimen to help avoid anesthesia-related complications as well as the appropriate type of facility to conduct proposed procedures.

The selection of facility and anesthesia regimen is also significantly impacted by both the age and mental status of an individual. Younger children or those with diminished mental capacity may have little understanding of why they need a dental procedure or how it is to be conducted. This may make them more anxious and difficult to operate on. In these populations, higher levels of sedation may be required to mitigate anxiety as well as allow the procedure to be successfully undertaken. In such patients a higher level of facility may be warranted for these individuals.

Definitions

Anesthesia services: Medical services wherein the delivery of anesthetic medications and services are delivered. This includes delivery of local and general anesthesia as well as intubation and respiratory support services.

Dental services: In the case of this document, any surgical procedure involving the oral cavity or mandibles.

Medically compromised individuals: Individuals that have serious medical conditions that increase their risk of medical complications.

Restorations: A surgical procedure that is intended to restore an individual’s anatomy to normal function and or appearance.

References

Peer Reviewed Publications:

  1. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985; 32(4):429-434.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatric Dentistry. Technical Report 2-2012: An Essential Health Benefit: General Anesthesia for Treatment of Early Childhood Caries. Available at: http://www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf. Accessed on January 29, 2018.
  2. American Academy of Pediatric Dentistry (AAPD). Guideline on Behavior Guidance for the Pediatric Dental Patient. 2016. Available at: http://www.aapd.org/media/Policies_Guidelines/G_BehavGuide.pdf. Accessed on February 9, 2018. 
  3. American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. Patient Assessment and Anesthesia in Outpatient Facilities. 2012. Available at:  https://www.aaoms.org/images/uploads/pdfs/parcare_assessment.pdf. Accessed on January 29, 2018.
  4. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. 2014. Available at: http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf. Accessed on January 29, 2018.
  5. American Society of Anesthesiologists. Physical Status Classification System. October 15, 2014. Available at: https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system.  Accessed on January 29, 2019
  6. Ashley PF, Williams CECS, Moles DR, Parry J. Sedation versus general anaesthesia for provision of dental treatment to patients younger than 18 years. Cochrane Database Syst Rev. 2015;(9):CD006334.
  7. Sherwood ER, Williams CG, Prough DS. Anesthesiology principles, pain management, as conscious sedation. In: Sabiston Textbook of Surgery. Townsend Cm, Beauchamp RD, Evers BM, Mattox KL, Eds. 2012. Elsevier Saunders. Philadelphia, PA.
History

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion/General Information and References sections.

 

10/01/2017

Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes.

Reviewed

05/04/2017

(MPTAC review. Updated formatting in the Clinical Indications section. Updated References section.

 

01/01/2017

Updated Coding section with 01/01/2017 CPT changes; removed codes 99143-99145 and 99148-99150 deleted 12/31/2016.

Reviewed

05/05/2016

MPTAC review. Updated References section. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated References section.

Reviewed

05/15/2014

MPTAC review.

Revised

05/09/2013

MPTAC review. The medically necessary criteria regarding “somatoform disorders” was revised after an additional vote post-MPTAC to replace the term “somatoform disorders” with “significant behavioral health conditions or psychiatric disorders.” Updated References section.

New

02/14/2013

MPTAC review. Initial document development.