D9248
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation demonstrating that sedation or anesthesia is necessary to safely provide the dental procedure.
- Documentation that the sedation/anesthesia was administered by trained, certified providers and that the facility was appropriately equipped and staffed (particularly for pediatric deep sedation/general anesthesia).
- Clinical documentation of extreme anxiety/fear and records showing failed attempts at local anesthesia, nitrous oxide, or oral conscious sedation.
- Dental and medical records substantiating any physical, cognitive, or developmental disability.
Key Coverage Criteria
- Intravenous moderate sedation may be used in the dental office, inpatient hospital, or ambulatory surgical center when necessary to safely provide dental care.
- Intravenous deep sedation or general anesthesia may be used in the dental office, inpatient hospital, or ambulatory surgical center when necessary to safely provide dental care.
- In-office deep sedation or general anesthesia may be appropriate for select pediatric dental patients when administered in appropriately equipped and staffed facilities.
- Intravenous moderate sedation, intravenous deep sedation, or general anesthesia when all general criteria and place-of-service–specific criteria are met.
- Documented extreme anxiety or fear with failed attempts at local anesthesia, nitrous oxide inhalation, or oral conscious sedation.
- Documented physical, cognitive, or developmental disability (e.g., congenital cardiac defect, cerebral palsy, epilepsy) that renders the patient non-compliant with dental care.
1 Active Policy
AMBETTER-CP.MP.61 — IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures
Related Codes
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