Clinical UM Guideline

Subject:Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Guideline #:  CG-MED-41Current Effective Date:  06/28/2016
Status:ReviewedLast Review Date:  05/05/2016


This document addresses the use of moderate to deep anesthesia services utilized in the facility setting when used to treat individuals undergoing dental procedures. This excludes the office setting.

Note: Please see the following related document for additional information:

Clinical Indications

Medically Necessary:                                                                                

The use of moderate to deep anesthesia services during the delivery of dental services is considered medically necessary when submitted documentation (including narrative, radiographs, etc.) demonstrates the presence of any of the following circumstances:

  1. Children (up to 20 years of age) requiring extensive operative procedures (such as multiple restorations, treatment of abscesses or oral surgical procedures), when in-office treatment (nitrous oxide or IV sedation) is not appropriate and hospitalization is not solely based upon reducing, avoiding or controlling apprehension; OR
  2. Individuals requiring extensive dental procedures and classified by the American Society of Anesthesiologists (ASA) as class 3 or class 4; OR
  3. Individuals requiring extensive dental procedures and classified with a Mallampati score of 3 or 4; OR
  4. Medically compromised patients whose medical history indicates that the monitoring of vital signs or the availability of resuscitative equipment is necessary during dental procedures; OR
  5. Individuals requiring extensive dental procedures with a medical history of uncontrolled bleeding, severe cerebral palsy or other medical condition that renders in-office treatment not medically appropriate; OR
  6. Individuals requiring extensive dental procedures who have documentation of significant behavioral health conditions or psychiatric disorders that require special treatment (for example, severe panic disorder); OR
  7. Cognitively disabled individuals requiring extensive procedures whose prior history indicates hospitalization is appropriate; OR
  8. Hospitalized individuals who need extensive restorative or surgical procedures.

Not Medically Necessary:

The use of moderate to deep anesthesia services during the delivery of dental services is considered not medically necessary when the above criteria have not been met.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

00170Anesthesia for intraoral procedures, including biopsy; not otherwise specified
99143-99145Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status [includes codes 99143, 99144, 99145]
99148-99150Moderate sedation services (other than those services described by codes 00100-01999) provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports [includes codes 99148, 99149, 99150]
 CPT Physical Status Modifiers
P1A normal healthy patient (Class I)
P2A patient with mild systemic disease (Class II)
P3A patient with severe systemic disease (Class III)
P4A patient with severe systemic disease that is a constant threat to life (Class IV)
D9220-D9221Deep sedation/general anesthesia
ICD-10 Diagnosis 
K00.0-K00.9Disorders of tooth development and eruption [includes codes K00.0, K00.1, K00.2, K00.3, K00.4, K00.5, K00.6, K00.7, K00.8, K00.9]
K01.0-K01.1Embedded and impacted teeth
K02.3-K02.9Dental caries [includes codes K02.3, K02.51, K02.52, K02.53, K02.61, K02.62, K02.63, K02.7, K02.9]
K03.0-K03.9Other diseases of hard tissues of teeth [includes codes K03.0, K03.1, K03.2, K03.3, K03.4, K03.5, K03.6, K03.7, K03.81, K03.89, K03.9]
K04.0-K04.99Diseases of pulp and periapical tissues [includes codes K04.0, K04.1, K04.2, K04.3, K04.4, K04.5, K04.6, K04.7, K04.8, K04.90, K04.99]
K05.00-K06.9Gingivitis and periodontal diseases [includes codes K05.00, K05.01, K05.10, K05.11, K05.20, K05.21, K05.22, K05.30, K05.31, K05.32, K05.4, K05.5, K05.6, K06.0, K06.1, K06.2, K06.8, K06.9]
K08.0-K08.9Other disorders of teeth and supporting structures [includes codes K08.0, K08.101, K08.102, K08.103, K08.104, K08.109, K08.111, K08.112, K08.113, K08.114, K08.119
M26.70-M26.79Dental alveolar anomalies [includes codes M26.70, M26.71, M26.72, M26.73, M26.74, M26.79]
M26.81-M26.82Soft tissue impingement; anterior or posterior
Discussion/General Information

The selection of where to conduct dental procedures is based on a wide variety of factors, including the health of the individual and the type of procedure proposed. These factors will significantly impact the type of anesthesia used during the procedure. Usually for routine and simple procedures in healthy individuals the dental or oral surgeon's office is an appropriate site. Alternatively, for complex procedures or for unhealthy individuals, a hospital operating room may be appropriate. For many individuals and procedures, other places of service, such as outpatient surgery centers, may be appropriate. This is because the risk of surgical and anesthesia complications increases with decreasing health of the individual and an increasing level of procedural complexity. As the risk of complications increases, so does the need for the appropriate equipment, personnel and other resources to deal with them should they occur. Higher level facilities such as outpatient surgical centers are more able to deal with adverse events because they are properly equipped with trained personnel and the tools and medications which may be required.

The goal of anesthesia during dental procedures, including tooth extractions and reconstructions, is intended to control and mitigate the incidence of pain, fear, and anxiety during the procedure. There is a wide variety of medications available that can be used to meet these goals, each with its own benefits and risks. These medications range from local anesthetics to numb the anatomic area being addressed to full general anesthesia that places the individual unconscious and immobilized. The selection of the appropriate medications to be used in any given situation is based on many factors, including the health and mental state of the individual as well as the extent of the proposed procedure. Generally, the more complex the procedure the more sedation and pain control needed, and the stronger medications that are required. This needs to be balanced with the frequently not-insignificant risks posed by the more powerful medications due to their interactions with various health conditions which may be adversely affected by their use. Conversely, some individuals with serious health conditions may require stronger medications than healthier individuals to allow doctors to conduct necessary procedures in a safe and effective manner.

One tool commonly used as a guide in the decision making process is the American Society of Anesthesiologists (ASA) Physical Status Classification System. This system is used to evaluate the overall health of the individual to identify his or her risk of complications during surgery, and to assist in identifying system-specific health conditions that may require tailored anesthetic regimens to avoid complications and provide the most appropriate care. The ASA classification system is as follows, and is derived by a thorough evaluation of an individual's overall health as assessed by a healthcare provider's review of an individual's health, family history, medications used, diet, and other factors:

Another tool used by anesthesiologists and other medical providers concerned with upper airway management is the Mallampati score. This score is used to assess oropharyngeal anatomy by gauging the visibility of structures in the oral pharynx, and is used to estimate the difficulty in maintaining upper airway in the event breathing is compromised during medical procedures. The score ranges from complete visualization, including the tonsillar pillars (class I), to no visualization at all, with the tongue pressed against the hard palate (class IV). Class I and Class II predict adequate oral access, Class III predicts moderate difficulty, and Class IV predicts a high degree of difficulty (Mallampati, 1985; Sherwood, 2012). The full scoring schema is below:

Class 1: Visualization of the soft palate, fauces, uvula, and anterior and posterior pillars.
Class 2: Visualization of the soft palate, fauces, and uvula.
Class 3: Visualization of the soft palate and the base of the uvula.
Class 4: Soft palate not visible at all.

The ASA document "Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia" (2014) provides clear definitions for Moderate and Deep sedation:

The American Association of Oral and Maxillofacial Surgeons (AAOMS) published the Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery for Patient Assessment and Anesthesia in Outpatient Facilities (2012). These documents provide guidance for the selection of anesthetic regimens during oral and maxillofacial surgery as well as a specific guide for the evaluation of individuals undergoing various types of anesthetic regimens. They specifically identify three specific populations of individuals at higher risk of complications due to anesthesia delivery, including pregnant women, children, and those with obesity.  These populations present with a significantly higher risk of anesthesia and surgical complications due to physiological and anatomical variations that may affect drug metabolism, access to the upper airway, or in the case of pregnancy, exposure to drugs with poorly studied effects on the fetus. The AAOMS also identifies many health conditions that may impact or be impacted by anesthesia, including asthma, diabetes, cardiac disease, hematologic diseases, and familial risk for malignant hyperthermia. The more powerful drugs in the anesthetic armamentarium may have significant impact on a wide variety of physiologic systems including respiration, heart function and glucose metabolism, which in compromised individuals may temporarily alter the function of the body and increasing the risk of adverse events. Identifying individuals with specific health conditions that create susceptibility to complications allows health care providers to choose the most appropriate anesthesia regimen to help avoid anesthesia-related complications as well as the appropriate type of facility to conduct proposed procedures.

The selection of facility and anesthesia regimen is also significantly impacted by both the age and mental status of an individual. Younger children or those with diminished mental capacity may have little understanding of why they need a dental procedure or how it is to be conducted. This may make them more anxious and difficult to operate on. In these populations higher levels of sedation may be required to mitigate anxiety as well as allow the procedure to be successfully undertaken. In such patients a higher level of facility may be warranted for these individuals.


Anesthesia services: Medical services wherein the delivery of anesthetic medications and services are delivered. This includes delivery of local and general anesthesia as well as intubation and respiratory support services.

Dental services: In the case of this document, any surgical procedure involving the oral cavity or mandibles.

Medically compromised individuals: Individuals that have serious medical conditions that increase their risk of medical complications.

Restorations: A surgical procedure that is intended to restore an individual's anatomy to normal function and or appearance.


Peer Reviewed Publications:

  1. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985; 32(4):429-434.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatric Dentistry. Technical Report 2-2012: An Essential Health Benefit: General Anesthesia for Treatment of Early Childhood Caries. Available at: Accessed on January 30, 2016.
  2. American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. Patient Assessment and Anesthesia in Outpatient Facilities. 2012. Available at: Accessed on January 30, 2016.
  3. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. 2014. Available at file:///C:/Users/londovn/Downloads/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf. Accessed on January 30, 2016.
  4. Ashley PF, Williams CECS, Moles DR, Parry J. Sedation versus general anaesthesia for provision of dental treatment to patients younger than 18 years. Cochrane Database Syst Rev. 2015;(9):CD006334.
  5. Sherwood ER, Williams CG, Prough DS. Anesthesiology principles, pain management, as conscious sedation. In: Sabiston Textbook of Surgery. Townsend Cm, Beauchamp RD, Evers BM, Mattox KL, Eds. 2012. Elsevier Saunders. Philadelphia, PA.




Reviewed05/05/2016Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Reference section. Removed ICD-9 codes from Coding section.
Reviewed05/07/2015MPTAC review. Updated Reference section.
Reviewed05/15/2014MPTAC review.
Revised05/09/2013MPTAC review. The medically necessary criteria regarding "somatoform disorders" was revised after an additional vote post-MPTAC to replace the term "somatoform disorders" with "significant behavioral health conditions or psychiatric disorders." Updated reference section.
New02/14/2013MPTAC review. Initial document development.