Dental Therapy Under General Anesthesia (TX.CP.MP.518)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP
| Additional Criteria for Facility Setting: Dental Therapy under General Anesthesia can be safely performed in an Ambulatory Surgical Center (ASC) setting. Should a facility, other than an ASC, have prior authorization requested for general anesthesia for dental therapy provided in a facility setting (HCPCS G0330) the provider will be required to include the medical necessity documentation for the requested setting.
Addition to policy include:
- Age-appropriate contraindications to an ASC setting:
- Members under age 21: Documented Health status is American Society of Anesthesiologist (ASA) physical status (PS) class 3 or higher (view policy language for full list)
- Members 21 years of age and older: ASA PS class 4 or higher (view policy language for full list).
Exceptions:
- Qualified ASC capable of providing the requested procedure
- Requesting provider does not have privileges at an ASC qualified to manage the procedure.
Added Section III – Contraindications and Exceptions for ASC setting, separated by age of member:
- It is the policy of Superior HealthPlan that dental therapy under general anesthesia can be safely performed in an Ambulatory Surgical Center (ASC) setting. Contraindications and exceptions to dental therapy under general anesthesia in an ASC setting are as follows:
- Members under 21 years of age: Documented Health status is American Society of Anesthesiologist (ASA) physical status (PS) class 3 or higher, or member meets one of the following:
- Member is less than 1 year of age.
- Recurrent bronchiolitis, reactive airway disease, and/or URI with lower airway symptoms under age 4.
- Immunocompromised.
- Medically Fragile state: Medically fragile is defined as a serious chronic physical condition that results in a prolonged dependency on medical care. An individual who is medically fragile requires daily skilled nursing intervention and is dependent upon medical devices/technology.
- Primary medical needs defined as member cannot live without mechanical supports or the services of others because of life-threatening conditions, including:
- The inability to maintain an open airway without assistance. This does not include the use of inhalers for asthma;
- The inability to be fed except through a feeding tube, gastric tube, or a parenteral route;
- The use of sterile techniques or specialized procedures to promote healing, prevent infection, prevent cross-infection or contamination, or prevent tissue breakdown;
- Multiple physical disabilities, including sensory impairments.
- Technologically dependent.
- Neuromuscular disease.
- Members 21 years of age and older: Documented Health status is American Society of Anesthesiologist (ASA) physical status (PS) class 4 or higher, or member has one of the following medical conditions:
- Personal history or family history of severe complication of anesthesia including, but not limited to malignant hyperthermia;
- BMI (body mass index) > 50;
- Member has severe uncontrolled obstructive sleep apnea;
- Uncompensated chronic heart failure (NYHA class III or IV);
- History of myocardial infarction in past 6 months;
- Coronary artery disease with ongoing cardiac ischemia requiring ongoing medical management, or placement of a STENT in last 6 months;
- Significant uncompensated valvular heart disease;
- Symptomatic cardiac arrhythmia despite medication;
- Cardiomyopathy with EF < 30%;
- Poorly controlled asthma (FEV1 < 80% despite medical management);
- Advanced liver disease (MELD Score > 8);
- Operative time expected >3 hours and combined operative and recovery time is anticipated to be > 23 hours;
- Exceptions:
- Qualified ASC capable of providing the requested procedure is not available in the members’ county as designated by HHSC [see Attachment B-5 for county designation].
- Distance and Travel Time to Qualified ASC:
- Metro: 45 minutes, 30 miles
- Micro: 80 minutes, 60 miles
- Rural: 75 minutes, 60 miles
- Requesting provider does not have privileges at an ASC qualified to manage the procedure.
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