General Anesthesia denials in California external review

What the reviewers wrote

Where the denial was overturned

A 53-year-old male has requested coverage for past anesthesia services provided during an esophagogastroduodenoscopy. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patient’s case. The American Society of Anesthesiologists notes that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication, with or without analgesia, to achieve a state of depressed consciousness while maintaining the patient’s ability to respond to stimulation.

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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate for mentally or physically challenged patients.

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.

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 General Anesthesia, then check the rights and deadlines that apply to your plan.