Partnership Health Plan of California

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Partnership Health Plan of California


Policy/Procedure Number: MPUP3048 (previously MCUP3048 & KKUM103)

Lead Department: Health Services

Policy/Procedure Title: Dental Services (including Dental Anesthesia)

 External Policy

 Internal Policy

Original Date: 9/20/2000 - Medi-Cal

11/16/2005 (KK UM103) - Healthy Kids

Next Review Date: 04/20/2017

Last Review Date: 04/20/2016

Applies to:


 Healthy Kids


Reviewing Entities:


 P & T






Approving Entities:









Approval Signature: Robert Moore, MD, MPH

Approval Date: 04/20/2016


  1. MCUP3041 - TAR Review Process


  1. Health Services

  2. Claims

  3. Member Services


  1. N/A


  1. N/A


To define the coverage under which Partnership HealthPlan of California (PHC) authorizes and reimburses for dental anesthesia for all lines of business and dental services for Medi-Cal and Healthy Kids Programs.


A. For all lines of business, PHC provides benefit coverage for medical services related to dental services including medications, laboratory services, pre-admission physical examinations required for admission to an outpatient/inpatient service, facility fees, and dental anesthesia.

B. PHC provides benefit coverage for the topical application of fluoride for children younger than age six (6), up to three (3) times in a 12 month period.
C. PHC is responsible for services related to dental procedures that require general anesthesia and are provide by individuals other than dental personnel, including any associated prescription drugs, laboratory services, physical examinations required for admission to a medical facility, outpatient surgical center services and inpatient hospital services required for a dental procedure.
D. Dental anesthesia services for children under age 12 require prior authorization from PHC. Treatment Authorization Requests (TARS) must be submitted to PHC electronically through PHC’s online services system or in writing via facsimile at (707) 863-4118.
E. A TAR is not required prior to delivering intravenous sedation or general anesthesia as part of an outpatient dental procedure in a state certified skilled nursing facility (SNF) or any category of intermediate care facility (ICF) for the developmentally disabled per California Department of Health Care Services (DHCS) All Plan Letter 15-012.
F. Actual decisions for determining medical necessity for dental anesthesia in individual cases take into account the needs for individual patients and the characteristics of the local delivery system.
G. Providers are required to adhere to all regulatory requirements (Federal, State, Licensing Board, etc) for:

  1. Preoperative and perioperative care

  2. Monitoring and equipment requirements

  3. Emergencies and transfers

  4. Monitoring guidelines

H. Criteria

1. Members may receive treatment for a dental procedure provided under general anesthesia by a physician anesthesiologist in the settings listed below only if PHC determines the setting is appropriate and according to criteria:

  1. Hospital

  2. Accredited ambulatory surgical center (stand-alone facility)

  3. Dental Office; and

  4. A Community Clinic that:

  1. Accepts Medi-Cal dental program or Healthy Kids beneficiaries

  2. Is a non-profit organization; and

  3. Is recognized by the Department of Health Care Services as a licensed community clinic or a Federally Qualified Health Center (FQHC) or FQHC look-alike.

2. If sedation is indicated then the least profound procedure should be attempted first. The procedures ranked from low to high profundity in the following order:

      1. Conscious Sedation via inhalation or oral anesthetics

      2. Intravenous (IV) sedation

      3. General Anesthesia

3. If the provider documents both a. and b. below, then the member shall be considered for IV sedation general anesthesia:

    1. Failure of Behavioral Modification AND

    2. Failure of conscious sedation, either inhalation or oral

4. If the provider documents any one of the following then the member shall be considered for IV sedation or general anesthesia:

a. Failure of effective communication techniques and the inability for immobilization (member may be dangerous to self or staff)

  1. Patient requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or conscious sedation.

  2. Patient has acute situational anxiety due to immature cognitive functioning

  3. Patient is uncooperative due to certain physical or mental compromising outcomes.

5. Members with certain medical conditions, such as but not limited to: moderate to severe asthma, reactive airway disease, congestive heart failure, cardiac arrhythmias, and significant bleeding disorders should be treated in a hospital setting or licensed facility capable of responding to a serious medical crisis.

6. The anesthesiologist performing anesthesia or sedation will be responsible for conducting a pre-operative history and focused physical to assess any interaction risk and plan accordingly per the American Society of Anesthesiologists’ “Basic Standards for Preanesthesia Care.” October 20, 2010

7. PHC recommends medical and dental procedures follow the recommendations of the American Academy of Pediatrics – Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures (see VII. A. References).
I. Members Insured under Healthy Kids
PHC reimburses for dental services through Delta Dental for Healthy Kids and e lines of business members only. The following applies to Healthy Kids.

1. PHC Healthy Kids members should contact Delta Dental directly at 1-877-580-1042 Monday through Friday between 7:15 am and 5:00 pm. In the case of emergency, they are available 24 hours seven days a week.

2. For routine care, availability is limited to network providers. Network providers agree to work with Delta if services needed require prior approval.

3. In the event of an emergent or urgently needed services (defined as those-reasonably believed to be required for treatment of severe pain, swelling or bleeding or the immediate diagnosis and treatment of unforeseen dental conditions which, if not diagnosed and treated immediately would lead to serious deterioration in health, disability or death ) prior approval is NOT required from Delta Dental, but is subject to post-service audit by review of appropriate diagnostic material in accordance with Title 22, CCR, Sections 51307 (a) (b) (e) (f) (g) and 51056 (c). A network dentist MUST be contacted if the member is within the service area.

4. When a member is outside of the service area, service may be obtained from any licensed dentist without prior approval from Delta Dental.

A. Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update, American Academy of Pediatrics, American Academy of Pediatric Dentistry, Charles J. Coté, MD, Stephen Wilson, DMD, MA, PhD the Work Group on Sedation , PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2587-2602 (doi:10.1542/peds.2006-2780)

B. California Code of Regulation, Title 10, Chapter 5.8, Article 3, Sections 2699.6700-6707, 67096711

C. Department of Health Care Services All-Plan letter 15-012

D. American Society of Anesthesiology “Basic Standards for Anesthesia Care.” October 20, 2010

E. Title 22, California Code of Regulations (CCR) Sections 51307 (a) (b) (e) (f) (g) and 51056 (c)


  1. PHC Provider Manual

  2. PHC Department Directors



10/17/01; 08/20/03; 10/20/04; 10/19/05; 10/18/06; 02/20/08; 04/21/10; 08/18/10; 10/20/10; 03/21/12; 06/19/13; 08/19/15; 04/20/16

Healthy Kids

02/20/08, 04/21/10; 08/18/10; 10/20/10; 03/21/12; 06/19/13; 08/19/15; 04/20/16



MPUP3048 - 02/20/2008 to 01/01/2015

Healthy Families:

MPUP3048 - 10/20/2010 to 03/01/2013

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

  • Consistent with sound clinical principles and processes

  • Evaluated and updated at least annually

  • If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

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