IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures

This policy covers intravenous moderate sedation, intravenous deep sedation, and general anesthesia for dental procedures in dental offices, ambulatory surgical centers, or inpatient hospitals. It is intended for patients such as select pediatric patients (including some under age 8 when ASA I–II), those with extreme anxiety, physical/cognitive/developmental disabilities, allergy to local anesthesia, or who require extensive/complex procedures, and is limited to cases meeting specified general and place‑of‑service criteria and administered by appropriately equipped, staffed, and certified providers with required monitoring, documentation and PALS‑certified personnel; services are not covered for convenience, for patients with significant comorbidities or disqualifying ASA status in office settings, or when provider qualifications/monitoring requirements are unmet.

"Intravenous moderate sedation may be used in the dental office, inpatient hospital, or ambulatory surgical center when necessary to safely provide dental care."