24-109m Find Out What Changed: Sedation and Anesthesia Coverage for Dental Services

Date: 01/31/24

All Plan Letter 23-028 affects medical providers and prior authorization requirements.

California Department of Health Care Services (DHCS) All Plan Letter (APL) 23-028, Dental Services – Intravenous Moderate Sedation and Deep Sedation/General Anesthesia Coverage, dated October 3, 2023, describes the requirements for Medi-Cal managed care health plans (MCPs) to cover intravenous (IV) moderate sedation and deep sedation/general anesthesia services provided by a physician in conjunction with dental services for MCP members in hospitals, ambulatory medical surgical settings or dental offices.¹

APL 23-028 supersedes APL 15-012 and outlines information that Health Net and its delegated subcontractors must review and consider during the prior authorization process, as described in the APL and detailed in the APL’s Attachment A for IV moderate sedation and deep sedation/general anesthesia for dental procedures.¹

Health Net’s prior authorization requirements have been updated to reflect the changes described in APL 23-028. Prior authorization requirements are posted in the Provider Library.

How this affects you

The DHCS developed consistent criteria and guidelines for IV moderate (conscious) sedation/analgesia (procedures D9239/D9243) and deep sedation/general anesthesia (procedures D9222/D9223) across all delivery systems and programs.¹

• Providers are required to submit requests for authorization (RAs)/prior authorizations (PAs)/Treatment Authorization Requests (TARs) for the provision of IV moderate sedation and deep sedation/general anesthesia services. The provider who renders the IV moderate sedation and/or deep sedation/general anesthesia service is responsible for submitting the authorization request. Submission and criteria requirements are outlined in the Manual of Criteria (MOC), Section 5 of the Medi-Cal Dental Provider Handbook.
• Providers are required to abide by any updated requirements outlined in the Medi-Cal Dental Provider Handbook and/or Medi-Cal Dental Provider Bulletins.
• Health Net’s member selection for conducting dental procedures under IV moderate sedation or deep sedation/general anesthesia utilizes medical history, physical status, and indications for anesthetic management. The DHCS expects that the dental provider will work collaboratively with an anesthesia provider to determine whether a member meets the minimum criteria necessary for receiving IV moderate sedation and/or deep sedation/general anesthesia. The need for moderate sedation and/or deep sedation/general anesthesia should be evaluated using the clinical judgment of the provider(s) based on the criteria indications delineated below.
  • The anesthesia provider must submit documentation outlining the member’s need for IV moderate sedation and/or deep sedation/general anesthesia based on such criteria indications through an RA/PA/TAR, and must receive approval prior to delivering the requested sedation or anesthesia services.
  • Prior to anesthesia services being rendered, the provider must have a copy of a complete history and physical examination and the indication for IV moderate sedation or deep sedation/general anesthesia.
  • Additionally, and not as a prerequisite to authorization, the provider must meet the requirements for chart documentation which, in addition to above, includes diagnosis, treatment plan and documentation of perioperative care (preoperative, intraoperative and postoperative care) for the dental procedure pertinent to the request.
• An RA/PA/TAR is not required prior to delivering IV moderate sedation or deep sedation/general anesthesia as part of an outpatient dental procedure in a state certified skilled nursing facility or any category of intermediate care facility for the developmentally disabled. Additionally, the dental provider must meet the requirements for chart documentation consistent with the MOC.
• The need for an RA/PA/TAR may be waived when there is documentation of an emergency condition justifying the immediate need for the procedure. However, these claims will be subject to additional review.

Additional requirements¹

Other requirements described in APL 23-028 include, but are not limited to:

• APL 23-028 updates terms “IV sedation” and “general anesthesia” to “IV moderate sedation” and “deep sedation/general anesthesia,” respectively.
• Health Net must authorize privileges for Medi-Cal dental providers who need to use anesthesiology at MCP facilities, or coordinate for out-of-network access for their members if a participating facility is not available, in accordance with timely access standards for specialty care.
• During an inpatient stay, authorization for general anesthesia provided by a physician anesthesiologist to a member must be part of the authorization for the inpatient admission. This does not preclude any subsequent inpatient stay necessary due to an outpatient procedure. In addition, an inpatient stay is not required for the provision of outpatient surgical center services.

All Medi-Cal members enrolled with Health Net are eligible for Medi-Cal dental services and are entitled to dental services under IV moderate sedation and deep sedation/general anesthesia when medically necessary in an appropriate setting. Health Net must provide prior authorization for IV moderate sedation and deep sedation/general anesthesia for dental services using the criteria provided in APL 23-028’s Attachment A.

Health Net will assist providers and members with the prior authorization process as a form of care coordination to avoid situations where services are unduly delayed.

The following lists Health Net’s coverage for IV moderate sedation and deep sedation/general anesthesia services:

Contractual responsibilities

• Health Net covers services related to dental procedures that require IV moderate sedation and deep sedation/general anesthesia and are provided by individuals other than a dental provider, including, but not limited to, any associated contractually required prescription drugs, laboratory services, physical examinations required for admission to a medical facility, outpatient surgical center services, and inpatient hospitalization services required for a dental procedure;
• Health Net reimburses facility fees for services provided in any hospital, or ambulatory surgery center, that meet the requirements set forth in this policy provided by dental providers or individuals other than dental providers; and
• Health Net coordinates all necessary non-anesthesia covered services provided to an MCP member.

Treatment requirements

Members may receive treatment for a dental procedure provided under IV moderate sedation and deep sedation/general anesthesia by a physician anesthesiologist in the settings listed below only if Health Net determines the setting is appropriate and according to the criteria outlined in the APL’s Attachment A:

• Hospital;
• Accredited ambulatory surgical center (stand-alone facility);
• Dental office; and
• A community clinic that:
• Participates in the provision of Medi-Cal dental services (dental FFS or DMC plan);
• Is a non-profit organization; and
• Is recognized by the DHCS as a licensed community clinic or a Federally Qualified Health Center (FQHC) or FQHC look-alike, including Tribal Health Program clinics.

Reimbursement scenarios

For more information on reimbursement for dental services provided in settings including dental offices, dental-only surgery centers, ambulatory surgical centers and general acute care hospitals, view APL 23-028, Attachment A and Attachment B, “Intravenous Moderate Sedation and Deep Sedation/General Anesthesia: Prior Authorization/Treatment Authorization Request and Reimbursement Scenarios” on the DHCS website.

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal. 

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more. If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6110.

¹ Taken or derived from APL 23-028, ​Dental Services – Intravenous Moderate Sedation and Deep Sedation/General Anesthesia Coverage (PDF); Attachment A: Policy for Intravenous Moderate Sedation and Deep Sedation/General Anesthesia (PDF) and/or Attachment B: Prior Authorization/Treatment Authorization Request and Reimbursement Scenarios (PDF).

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Amador, Los Angeles, Calaveras, Sacramento, Inyo, Mono, San Joaquin, Stanislaus, Tuolumne, and Tulare counties.