Medical policy: Dental and Oral Surgery Procedures Performed in a Facility

Número de política: MP 1.092

Beneficio clínico

  • Minimizar el riesgo o la preocupación de seguridad.
  • Minimizar las intervenciones dañinas o ineficaces.
  • Garantizar el nivel de atención adecuado.
  • Asegurar la duración adecuada del servicio para las intervenciones.
  • Asegurar que se hayan cumplido los requisitos médicos recomendados.
  • Asegurar el lugar apropiado para el tratamiento o servicio.

Fecha de entrada en vigor: 9/1/2026

Política

General anesthesia, including associated medical services, as well as a facility admission, either inpatient or outpatient/observation, may be considered medically necessary for the following:

  • Individuals (adult or children) who have a medically significant condition (e.g. unstable heart disease, severe asthma, severe chronic obstructive pulmonary disease, seizures, hemophilia); or
  • Individuals (adult or children) who have a history of severe postoperative complications following oral or dental surgery; or
  • Individuals (adult or children) scheduled for dental or oral surgical procedures which have a high probability of complications; or
  • Individuals who are 7 years or younger; or
  • Individuals who are developmentally disabled.

Cross-references:

  • MP 1.004 Cosmetic and Reconstructive Surgery
  • MP 1.154 Procedures Completed in an Ambulatory Surgery Center Using General or Regional Anesthesia

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Consulte el Manual de Políticas Médicas de FEP.

Descripción/Antecedentes

Occasionally, a patient's age or health status may require the use of a medical facility to render routine dental care or other covered or non-covered dental and oral surgery procedures. A facility admission may also be required when there is a high probability of complications.

The Children and Developmentally Disabled Patient Access to Quality Dental Care Act (Act 94 of 2012) is a PA mandate that requires health insurers to cover general anesthesia and associated medical costs for eligible dental patients when they would fare better under general rather than local anesthesia. Eligible patients are those who are 7 years or younger or developmentally disabled for whom a successful result cannot be expected for treatment under local anesthesia and for whom a superior result can be expected for treatment under general anesthesia.

Per the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, examples of developmental disabilities include ADHD, autism spectrum disorder, cerebral palsy, hearing loss, intellectual disability, learning disability, vision impairment, and other developmental delays.

General anesthesia is defined in Act 94 as a controlled state of unconsciousness, including deep sedation, that is produced by a pharmacologic method, a non-pharmacologic method, or a combination of both, and that is accompanied by a complete or partial loss of protective reflexes that include the patient’s inability to maintain an airway independently and to respond purposefully to physical stimulation or verbal command.

Definiciones

Associated Medical Services - Hospitalization and all related medical expenses normally incurred as a result of the administration of general anesthesia.

Developmental Disabilities - Development disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person’s lifetime.

General Anesthesia Services - A means of causing the loss of the ability to perceive pain due to the loss of consciousness produced by the infusion of medications or inhalation of anesthetic agents.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios del miembro, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: esta lista de códigos puede no ser exhaustiva y los códigos están sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

  • Specific codes do not apply to this policy.

Referencias

  1. Pennsylvania General Assembly. Act 94 of 2012, Children and Developmentally Disabled Patient Access to Quality Dental Care Act.
  2. Coté CJ, Wilson S; American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019;143(6):e20191000. (Reaffirmed Dec. 2025)
  3. American Academy of Pediatric Dentistry. Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient (Latest revision 2023). The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry; 2025:451-5
  4. American Academy of Pediatric Dentistry. Policy on medically-necessary care (Latest revision 2024). The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry; 2025:71-5.
  5. Ahmed SS, Hicks SR, Slaven JE, Nitu ME. Deep Sedation for Pediatric Dental Procedures: Is this a Safe and Effective Option?. J Clin Pediatr Dent. 2016;40(2):156-160. doi:10.17796/1053-4628-40.2.156
  6. Centros para el Control y la Prevención de Enfermedades. Developmental Disabilities. April 29, 2022.
  7. American Academy of Pediatric Dentistry. Policy on third-party reimbursement of medical fees related to sedation/general anesthesia for delivery of oral health care services (Latest revision 2022). The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry; 2025: 200-3.

Antecedentes de la política

MP 1.092

10/30/2012 Minor Review. Policy revised to add information related to The Children and Developmentally Disabled Patient Access to Quality Dental Care ACT (Act 94 of 2012) PA mandate. House Bill 532-Policy criteria for a facility admission changed from age (6) to age (7). References updated. FEP variation revised regarding dental admissions. Codes reviewed 10/17/2012

11/26/2013 Revisión de consenso. No changes to policy statements. References reviewed. Changed Medicare variation to reference Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication 100-02. Chapter 15 Dental Services. Payments are made for a covered dental procedure no matter where the service is performed. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.

04/01/2014 Actualización Administrativa. Coding Reviewed and updated. Specific codes not applicable to this policy.

11/25/2014 Revisión de consenso. References updated. No change to the policy statements. No coding on this policy as it relates to anesthesia and facility only.

01/26/2016 Revisión de consenso. No change to policy statements. References reviewed. Coding reviewed.

05/26/2016 Actualización Administrativa. Updated cross-references.

01/01/2017 Actualización Administrativa. Product variation section reformatted.

03/28/2017 Revisión de consenso. No change to the policy statements. References updated. Policy reviewed and specific codes do not apply to this policy.

01/01/2018 Actualización Administrativa. Medicare variations removed from Commercial Policies.

01/31/2018 Revisión de consenso. No change to the policy statements. References reviewed. Policy reviewed and specific codes do not apply to this policy.

02/05/2019 Revisión de consenso. No change to the policy statements. References reviewed.

02/19/2020 Revisión de consenso. Policy statement unchanged. References updated.

02/01/2021 Revisión de consenso. Policy statement unchanged. References updated.

01/25/2022 Revisión de consenso. No criteria changed. References updated.

02/20/2023 Revisión de consenso. Updated background, definitions, and references.

02/12/2024 Revisión de consenso. Updated cross-references. Reviewed references.

03/10/2025 Revisión de consenso. No criteria changes.

06/09/2025 Actualización Administrativa. Removing the Benefit Variations and updating the Disclaimer.

05/20/2026 Revisión de consenso. Editorial updates to policy stance with removal of specific examples of conditions with high probability of complications, no change to intent. Cross-references, background, definitions, and references updated.