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

Policy number: MP 1.092

Clinical benefit

  • Minimize safety risk or concern.
  • Minimize harmful or ineffective interventions.
  • Assure appropriate level of care.
  • Assure appropriate duration of service for interventions.
  • Assure that recommended medical prerequisites have been met.
  • Assure appropriate site of treatment or service.

Effective date: 9/1/2026

Policy

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

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/Background

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.

Definitions

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.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

  • Specific codes do not apply to this policy.

References

  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. Centers for Disease Control and Prevention. 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.

Policy history

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 Consensus Review. 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 Administrative Update. Coding Reviewed and updated. Specific codes not applicable to this policy.

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

01/26/2016 Consensus Review. No change to policy statements. References reviewed. Coding reviewed.

05/26/2016 Administrative Update. Updated cross-references.

01/01/2017 Administrative Update. Product variation section reformatted.

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

01/01/2018 Administrative Update. Medicare variations removed from Commercial Policies.

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

02/05/2019 Consensus Review. No change to the policy statements. References reviewed.

02/19/2020 Consensus Review. Policy statement unchanged. References updated.

02/01/2021 Consensus Review. Policy statement unchanged. References updated.

01/25/2022 Consensus Review. No criteria changed. References updated.

02/20/2023 Consensus Review. Updated background, definitions, and references.

02/12/2024 Consensus Review. Updated cross-references. Reviewed references.

03/10/2025 Consensus Review. No criteria changes.

06/09/2025 Administrative Update. Removing the Benefit Variations and updating the Disclaimer.

05/20/2026 Consensus Review. 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.