KAISER PERMANENTE Foundation Health Plan Southern California Instructions

KAISER PERMANENTE Foundation Health Plan Southern California

Utilization Management Criteria Statement

This document includes criteria that supports utilization review of certain provider requested health care services.

Utilization review occurs when a qualified physician other than the treating clinician reviews the treating clinician’s request against utilization review criteria. The qualified physician is in the position to approve, deny, delay, or modify the service request based on a determination of medical necessity. These criteria are consistent with professional standards of practice and provided for your reference.

If you are in a treatment relationship with a member your clinical recommendations are not subject to these criteria. Your treatment recommendations are guided by your professional judgment and influenced, where applicable, by clinical practice guidelines and clinical support tools found in the library under “Guidelines”.

Principles

Dental Anesthesia Utilization Guidelines for Commercial and CMS

General Anesthesia (GA) and associated facility charges for dental procedures are covered when general anesthesia is provided in an in-plan hospital or surgery center setting and is medically necessary based on clinical status or a qualifying medical condition.

If the dental procedure ordinarily requires general anesthesia by nature of the procedure itself, regardless of the clinical situation, then neither the general anesthesia nor facility charges are covered.

The anesthesia and associated facility charges must meet Health Plan’s terms and conditions that apply generally to other covered services. For example, a Plan physician must determine that the services are medically necessary.

Clinical Review Criteria

Commercial

Medical necessity for general anesthesia in a hospital or surgery center setting requires that the following three criteria are met.

1. There must exist a medical condition, or the clinical status (including behavioral factors) as such, that general anesthesia is medically indicated and cannot be administered safely in an office setting. General anesthesia that can be safely provided in the dental office is not covered.
   An example of a clinical status which requires a hospital or outpatient surgical setting to be performed safely would be restoration for extensive multiple site decay in a patient with severe anxiety that has failed a trial of usual cognitive/behavioral modalities and/or appropriate anxiolytic therapy in the dental office setting. An example of a medical condition requiring that anesthesia be administered in a hospital or surgery center setting would be severe obstructive sleep apnea.
   AND

2. The patient must be less than 7 years of age, or be developmentally disabled, or have compromised health (including compromised mental/behavioral health) such that general anesthesia is medically indicated. A patient that is 7 or older who is not developmentally disabled, and whose physical or mental/behavioral health is not compromised to the point of requiring general anesthesia does not qualify.
   AND

3. The dental needs must be of significant complexity such that delay in treatment could lead to infection or other systemic complications. Routine dental exams and/or cleaning would not qualify as a medical indication for dental anesthesia.

From the American Academy of Pediatric Dentistry, Technical Report 2-2012 (See references)

The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered in the use of GA. The decision to use GA must take into consideration:

1. Alternative behavioral guidance modalities
2. Dental needs of the patient
3. The effect on the quality of dental care
4. The patient’s emotional development
5. The patient’s medical status

Objectives of GA:

1. Provide safe, efficient, and effective dental care
2. Eliminate anxiety
3. Reduce untoward movement and reaction to dental treatment
4. Aid in treatment of the mentally, physically, or medically compromised patient
5. Eliminate the patient’s pain response

EOC Commercial:

Coverage applies only when ALL of the following criteria are met:

a) The dental procedure would not ordinarily require general anesthesia. There are different types of dental anesthesia, however, ONLY general anesthesia is covered under the dental anesthesia benefit when it is determined by a Plan physician to be medically necessary, AND
b) The “member’s clinical status” (including behavioral factors) or “underlying medical condition”, requires that the dental procedure be provided in a hospital or outpatient surgery center setting. General anesthesia that can be safely provided in the dental office would not qualify, AND
c) The member for whom the treatment is proposed:

• is under seven (7) years of age, OR
• is developmentally disabled, regardless of age, OR
• is a person whose health is compromised and for whom general anesthesia is medically necessary.

Medicare

EOC for Medicare:

For dental procedures at a network facility, general anesthesia and the facility’s services associated with the anesthesia are provided if all of the following are true:

• You are developmentally disabled, or your health is compromised.
• Your clinical status or underlying medical condition requires that the dental procedure be provided in a hospital or outpatient surgery center.
• The dental procedure would not ordinarily require general anesthesia.

Note: There are no specific Medicare rules on dental anesthesia. The health plan did not take a federal exemption and opted to cover the benefit based on state regulations made applicable to the Medicare age group, e.g., age seven (7) was removed from the benefit and pediatric considerations would not apply to the criteria.

Contributors/ Clinical Experts

H.M. Fallah, DDS MD FACS FACOMS, Regional Chair of Chiefs of Maxillofacial Surgery William Cory, MD SCAL Health Plan UM Physician Advisor Mark S. Thomas, MD SCAL Regional Chief of Anesthesiology

Approving Bodies

John Brookey, MD, SCAL Health Plan UM Physician Advisor 11//2021, 11//2022, 08/2023 William Cory, MD SCAL Health Plan UM Physician Advisor 11/2021,11/2022,08/2023 Utilization Management Steering Committee (UMSC)11//2021, 11//2022, 08/2023

References

• American Academy of Pediatric Dentistry. Technical Report 2-2012: An Essential Health Benefit: General Anesthesia for Treatment of Early Childhood Caries. Available at: http://www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf.

• Recognition and Management of Complications During Moderate and Deep Sedation
  Part 1: Respiratory Considerations, Anesthesia Prog 58:82-92 2011 © 2011 by the American Dental Society of Anesthesiology

• 2012 Guidelines for the Use of Sedation and General Anesthesia by Dentists; American Dental Association 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: http://www.aaoms.org

Dental Anesthesia – Commercial
and Medicare UM Criteria 2023

References

• AAOMS

Read User Manual Online (PDF format)

Read User Manual Online (PDF format)  >>

Download This Manual (PDF format)

Download this manual  >>