Anthem Blue Cross Blue Shield of California policy
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting is a public Anthem Blue Cross Blue Shield of California policy (policy CG-MED-41). It lists 10 CPT or HCPCS codes, 10 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-MED-41
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 00170 | On the list | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | Policies naming 00170 |
| 99151 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age | Policies naming 99151 |
| 99152 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | Policies naming 99152 |
| 99153 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time | Policies naming 99153 |
| 99155 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age | Policies naming 99155 |
| 99156 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older | Policies naming 99156 |
| 99157 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time | Policies naming 99157 |
| D9222 | On the list | Deep sedation/general anesthesia first 15 minutes | Policies naming D9222 |
| D9223 | On the list | Deep sedation/general anesthesia - each subsequent 15 minute increment | Policies naming D9223 |
| G0330 | On the list | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | Policies naming G0330 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list