00170
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A carefully obtained and reviewed preoperative medical history and physical examination designed to identify high-risk patients with potential medical contraindications to office-based anesthesia.
- Laboratory tests as necessary based on preoperative assessment ("laboratory tests (as necessary)").
- Documentation of the reason local anesthesia is not appropriate or indicated when that is the basis for anesthesia (e.g., confirmed toxicity or allergy to local anesthesia; medical comorbidity; presence of acute infection at injection site).
- Documentation of patient age (e.g., age seven years or younger) or of severe psychological impairment/developmental disability when these are the indications for MAC/general anesthesia.
Key Coverage Criteria
- MAC/general anesthesia and associated facility charges in conjunction with dental surgery or procedures performed by a dentist, oral surgeon, or oral maxillofacial surgeon are considered medically necessary when there is an appropriately trained and licensed professional to both administer and monitor MAC/general anesthesia in EITHER of the following locations: a properly-equipped and staffed office; a hospital or outpatient surgery center.
- Individual for whom local anesthesia is not appropriate or indicated (i.e., due to confirmed toxicity or allergy to local anesthesia; medical condition comorbidity; or presence of acute infection at injection site for local anesthesia).
- Individual age seven years or younger.
- Individual who is severely psychologically impaired or developmentally disabled.
- Individual with American Society of Anesthesiologists (ASA) Physical Status Classification of 3 or greater.
- Individual who has one or more significant medical comorbidities which preclude the use of conscious sedation.
4 Active Policies
AMBETTER-CP.MP.61 — IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures
CIGNA-0415 — Anesthesia and Facility Services for Dental Treatment - (0415)
ANTHEM-CG-MED-21 — CG-MED-21 Anesthesia Services and Moderate (âConsciousâ) Sedation
ANTHEM-CG-MED-41 — CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Related Codes
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