CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

This policy addresses moderate to deep anesthesia services provided in a facility setting for dental surgery. Coverage is medically necessary only when both: (1) extensive dental procedures are planned (e.g., removal of two or more impacted third molars, extraction of six or more teeth, full-arch alveoplasty, placement/removal of two or more implants, or multi-quadrant periodontal flap surgery) and (2) documentation shows the individual requires a facility setting due to clinical status (e.g., currently hospitalized, under age 6, ASA class III–IV, or Mallampati score 3–4); it is not covered when these criteria are not met.

"Use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is consideredmedicallynecessarywhen the following criteria have been met (Aan..."

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