Dental Anesthesia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for general anesthesia in a hospital operating room setting during dental extraction surgery. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollee’s impacted teeth. A review of the records indicates the enrollee was diagnosed with impacted teeth. In an operative report, the enrollee’s provider noted that the enrollee had a disturbance of tooth eruption involving the secondary maxillary canines. The maxillary canines were horizontally impacted with crowns facing anteriorly. The roots of the adjacent teeth were close to the impacted teeth. The provider noted the procedure would be carried out in an operating room under general anesthesia due to the enrollee’s age and significant complexity of the procedure.

The parent of a one-year-old female enrollee has requested general anesthesia in a hospital or surgery center setting for treatment of the enrollee’s dental caries requiring pulpectomy. Findings: The physician reviewer found that coverage for general anesthesia in a hospital or surgery center setting is medically necessary for the patient’s dependent dental services. The patient has severe disease requiring extensive dental surgery. The patient is a one-year-old without fully developed oropharyngeal reflexes to protect the airway. General anesthesia provides a safe and effective setting for the dental surgery. General anesthesia also provides a controlled setting in which the patient’s airway is protected from excessive secretions and aspiration which can potentially put the patient at risk for respiratory distress.

Where the denial was upheld

The parent of a 17-year-old male has requested coverage for dental anesthesia services for treatment of his dental anxiety. Findings: The physician reviewer found that per the American Dental Association, sedation for dental procedures can fall into the following categories local anesthesia, minimal sedation, use of nitrous oxide/oxygen (when used in combination with sedative agents may provide minimal, moderate, deep sedation or general anesthesia), moderate sedation, deep sedation, and general anesthesia. The American Society of Anesthesiologists (ASA) discussed the definitions of moderate sedation, deep sedation, and general anesthesia. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Nature of Statutory Criteria/ Case Summary: The enrollee has requested health plan coverage for dental anesthesia for his impacted third molar/wisdom tooth extraction. Findings: The physician reviewer found that the enrollee has a history of asthma and a current diagnosis of impacted wisdom teeth. He was referred to a dental surgeon due to possible complications of wisdom tooth extractions. Due to the severity of extractions, the enrollee is unable to tolerate treatment at a local setting. The literature describes the circumstances under which general anesthesia for third molar extraction is deemed necessary. However, the vast majority are uncomplicated extractions that can be performed under local anesthesia in the outpatient setting. The literature does not support choosing general anesthesia over local anesthesia for third molar surgery.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Dental Anesthesia, then check the rights and deadlines that apply to your plan.