PARTNERSHIP HEALTH PLAN OF CALIFORNIA
POLICY/PROCEDURE
Policy/Procedure Number: MPUP3048 (previously MCUP3048 &
Lead Department: Health Services
KKUM103)
Policy/Procedure Title: Dental Services (including Dental
External Policy
Anesthesia)
Internal Policy
Original Date: 9/20/2000 - Medi-Cal
Next Review Date: 08/19/2016
11/16/2005 (KK UM103) - Healthy Kids
Last Review Date: 08/19/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
Approval Signature: Robert Moore, MD, MPH
CREDENTIALING
DEPT. DIRECTOR/OFFICER
Approval Date: 08/19/2015
I.
RELATED POLICIES:
A. MCUP3041 - TAR Review Process
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To define the coverage under which PHC authorizes and reimburses for dental anesthesia for all lines of
business and dental services for Medi-Cal and Healthy Kids Programs.
VI.
POLICY / PROCEDURE:
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 requires prior authorization from Partnership
HealthPlan of California (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. 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.
Page 1 of 4
Policy/Procedure Number: MPUP3048 (previously
Lead Department: Health Services
MCUP3048 & KKUM103)
☒External Policy
Policy/Procedure Title: Dental Services (including Dental
Anesthesia)
☐Internal Policy
Original Date: 9/20/2000 - Medi-Cal
Next Review Date: 08/19/2016
11/16/2005 (KK UM103) - Healthy Kids
Last Review Date: 08/19/2015
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
F. 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
G. 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:
a. Hospital
b. Accredited ambulatory surgical center (stand-alone facility)
c. Dental Office; and
d. 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:
a. Conscious Sedation via inhalation or oral anesthetics
b. Intravenous (IV) sedation
c. General Anesthesia
3. If the provider documents both a. and b. below, then the member shall be considered for IV sedation
general anesthesia:
a. Failure of Behavioral Modification AND
b. Failure of conscious sedation, either inhalation or oral
4. If the provider documents any one of the following then the member 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)
b. Patient requires extensive dental restorative or surgical treatment that cannot be rendered under
local anesthesia or conscious sedation.
c. Patient has acute situational anxiety due to immature cognitive functioning
d. 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 (continuous Coumadin therapy) 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 preoperative 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
www.asahq.org.
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).
Page 2 of 4
Policy/Procedure Number: MPUP3048 (previously
Lead Department: Health Services
MCUP3048 & KKUM103)
☒External Policy
Policy/Procedure Title: Dental Services (including Dental
Anesthesia)
☐Internal Policy
Original Date: 9/20/2000 - Medi-Cal
Next Review Date: 08/19/2016
11/16/2005 (KK UM103) - Healthy Kids
Last Review Date: 08/19/2015
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
H. 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.
VII.
REFERENCES:
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, 6709-6711
C. Department of Health Care Services All-Plan letter 15-012, issued May 14, 2015
D. American Society of Anesthesiology “Basic Standards for Anesthesia Care.” October 20, 2010
www.asahg.org
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Health Services Senior Director
X.
REVISION DATES:
Medi-Cal
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
Healthy Kids
02/20/08, 04/21/10; 08/18/10; 10/20/10; 03/21/12; 06/19/13; 08/19/15
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
MPUP3048 - 02/20/2008 to 01/01/2015
Healthy Families:
MPUP3048 - 10/20/2010 to 03/01/2013
Page 3 of 4
Policy/Procedure Number: MPUP3048 (previously
Lead Department: Health Services
MCUP3048 & KKUM103)
☒External Policy
Policy/Procedure Title: Dental Services (including Dental
Anesthesia)
☐Internal Policy
Original Date: 9/20/2000 - Medi-Cal
Next Review Date: 08/19/2016
11/16/2005 (KK UM103) - Healthy Kids
Last Review Date: 08/19/2015
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
*********************************
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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