Anesthesia Local anesthesia NOT in conjunction with operative or surgical procedures. Regional block Trigeminal division block. Deep sedation/general anesthesia provided by a dentist regardless of where the dental services are provided for a medical condition covered by this Policy which requires hospitalization or general anesthesia. 2 hour maximum time Intravenous conscious sedation/analgesia 2 hour maximum time – Nitrous oxide/analgesia Non-intravenous conscious sedation to include oral medications – Behavior management for additional time required to provide services to a child – with special needs that requires more time than generally required to provide a dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum 2 units – Inpatient/Outpatient hospital 4 units – Skilled Nursing/Long Term Care 2 units – Consultation by specialist or non-primary care provider Professional visits House or facility visit for a single visit to a facility regardless of the number – of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room services are provided for –dental patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation (during regular hours) no other service performed – Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments by report – Application of desensitizing medicament per visit – Occlusal guard for treatment of bruxism, clenching or grinding – Athletic mouthguard covered once per year Occlusal adjustment
Anesthesia Local anesthesia NOT in conjunction with operative or surgical procedures. Regional block Trigeminal division block. Deep sedation/general anesthesia provided by a dentist regardless of where the dental services are provided for a medical condition covered by this Policy which requires hospitalization or general anesthesia. 2 hour maximum time Intravenous conscious sedation/analgesia – 2 hour maximum time Nitrous oxide/analgesia Non-intravenous conscious sedation – to include oral medications Behavior management – for additional time required to provide services to a child with special needs that requires more time than generally required to provide a dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by specialist or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment
HMO%20POS%20EOC%202018%20A.docx