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:
III. It is the policy of Superior HealthPlan that dental therapy under general anesthesia is medically necessary when meeting one of the following:
- Anesthesia will be safely performed in an ambulatory surgical center (ASC) setting; or
- Anesthesia cannot be performed in an ASC due to one of the following:
- 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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