G0330 prior authorization | Blue Shield of California Promise Health Plan

G0330, 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, is on the Blue Shield of California Promise Health Plan Medi-Cal prior authorization list. Not a coverage or referral decision.

Code: G0330
Description: 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
Source: Medi-Cal Prior Authorization List, Pg 25 Original policy

Blue Shield of California Promise Health Plan prior authorization

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