Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Caries

Treatment D9222 general anesthetic- first 15 minutes and D9223 general anesthesia- each 15 minutes x 5

The insurer denied coverage for D9222 general anesthetic- first 15 minutes and D9223 general anesthesia- each 15 minutes x 5.	

The denial is upheld.

According to the documentation submitted, this is a patient with no documented history. He presented to the Dentist's office for an evaluation. The treating Oral Surgeon determined that the patient needed extractions with general anesthesia. 

The plan stated that there was no documentation that general anesthesia was needed and that the treatment was also denied because the patient was not having four or more teeth removed. With the documentation available, there is no clinical documentation showing that the general anesthesia is necessary as there is no letter of medical necessity, examination notes nor radiographs. The documentation states that four wisdom teeth are being removed but there is no clinical documentation of this with radiographs.

In general, the decision to use sedation/general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. Pain and anxiety resulting from disease or fear of impending surgery affect all surgical disciplines. The control of pain and anxiety using the techniques of regional (local) anesthesia, all forms of sedation and general anesthesia have been an integral part of the practice of oral and maxillofacial surgery since inception of the specialty. Working with knowledge and skills developed during years of required training and expanded through daily experience, oral and maxillofacial surgeons are usually able to identify, diagnose, and assess the source of pain and anxiety within the scope of their discipline. The oral and maxillofacial surgeon utilizes a series of pain control modalities that interrupt or moderate the perception of pain and anxiety. The practitioner's selection of a particular technique for controlling pain and anxiety is individually determined for each patient.

Any additional anesthesia (D9223) is not medically necessary without the proper documentation. This would include the anesthesia record which documents the anesthesia time utilized. A patient's medical record should include:

1) documentation of the patient's history
2) physical examination findings
3) assessment and diagnosis, including differential diagnosis
4) all discussions, including the informed consent process before a procedure
5) the treatment provided
6) any plan for follow up, including discharge instructions given to the patient and
7) note any images taken, and the results/review of the images

In order to determine the medical necessity for this case, the clinical notes and a Panorex need to be provided. As noted, this information was not provided. The records were requested in writing and a follow-up phone call left a message requesting records. No additional records were submitted.

Based on the above, the medical necessity for the D9222 general anesthetic- first 15 minutes and D9223 general anesthesia- each 15 minutes x 5 is not substantiated. The insurer's denial is upheld.