Criteria
Coverage is subject to the specific terms of the member's benefit plan.
BCBSND considers general anesthesia medically necessary for Dental or OMS services if any of the following criteria is met:
Note: In general, coverage of medically necessary anesthesia services is available only in connection with underlying services that are covered under the medical benefits plan.
Please check your benefits plan to determine whether services are covered.
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Members who exhibit physical, intellectual, psychiatric, or medically compromising conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and which, under anesthesia, can be expected to produce a superior result. Conditions include but are not limited to mental retardation, cerebral palsy, epilepsy, cardiac problems and hyperactivity (verified by appropriate medical documentation);
or
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Members who are extremely uncooperative, unmanageable, or uncommunicative members with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity;
or
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Members that have severe anxiety for whom local anesthesia is ineffective or failed a prior attempt at office based-based procedures (such as due to acute infection, anatomic variations or allergy);
or
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Members who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised;
or
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Members with severe unstable diseases (American Society of Anesthesiologists (ASA) Class III or IV, which includes, but not limited to: poorly controlled diabetes mellitus, hypertension, COPD, morbid obesity with BMI greater than 40, cardiac ischemia or markedly reduced cardiac function or valve dysfunction, history
of
or anticipated intolerance to standard sedatives, such as chronic opioid use or chronic benzodiazepine use. Individuals with active medical problems related to drug or alcohol abuse) for whom the risk of extensive procedures performed under local anesthesia is considered unacceptable;
or
- extractions done in preparation for Radiation treatment (greater than or equal to two (2) extractions).
In all other circumstances, the use of General Anesthesia for dental procedures is considered to be
not medically necessary.
Procedure Code
