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Policy on Third-party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Care Services

Purpose

The American Academy of Pediatric Dentistry (AAPD), to ensure that all children have access to the full range of oral health delivery systems, advocates that if sedation or general anesthesia and related facility fees are payable benefits of a healthcare plan, these same benefits shall apply for the delivery of oral health services.

Methods

This policy was developed by the Dental Care Committee, and adopted in 1989. This document is an update of the previous policy, revised in 2011, and is based on a review of the current dental literature related to guidelines for sedation and general anesthesia, as well as issues pertaining to medically-necessary oral health care. The update included a PubMed®/MEDLINE search using the terms: general anesthesia/sedation costs, general anesthesia/sedation reimbursement, general anesthesia/sedation insurance coverage, and general anesthesia/oral health-related quality of life and limit: within the last 10 years as well as relevant articles from dental and medical literature. The search returned 95 articles. The reviewers agreed upon the inclusion of 24 articles that met the defined criteria. Relevant policies and guidelines of the AAPD and the American Dental Association (ADA) are included. Additionally, expert opinions and best current practices were relied upon when clinical evidence was not available.

Background

For some infants, children, adolescents, and persons with special health care needs, treatment under sedation/general anesthesia in a hospital, outpatient facility, or dental office or clinic represents the only viable method to deliver necessary oral health care.1-3  The patient’s age, dental needs, disabilities, medical conditions, and/or acute situational anxiety may preclude the patient from being treated safely in a traditional outpatient setting.3-8  These patients may be denied access to oral health care when insurance companies refuse to provide reimbursement for sedation/general anesthesia and related facility services. Most denials cite the procedure as not medically necessary. This determination appears to be based on inconsistent criteria.9-11  For instance, medical policies often provide reimbursement for sedation/general anesthesia or facility fees related to myringotomy for a three-year-old child, but deny these benefits when related to treatment of dental disease and/or infection for the same patient.

Dental rehabilitation of early childhood caries (ECC) has shown a significant improvement in oral health-related quality of life (QOL) in children.4,12-21  Children undergoing comprehensive dental treatment under general anesthesia exhibited improvement in several areas such as sleeping, eating, and pain.4,13-16  Parents reported their children to have a better perceived QOL one to four weeks following dental rehabilitation under general anesthesia.17  Dental treatment under general anesthesia is associated with significant improvements in the patient’s QOL and has been reported to have a positive impact on the family’s quality of life.12  ADA Resolution 1989-546 states that insurance companies should not deny benefits that otherwise would be payable “solely on the basis of the professional degree and licensure of the dentist or physician providing treatment, if that treatment is provided by a legally qualified dentist or physician operating within the scope of his or her training and licensure”.22

A majority of states have enacted legislation requiring medical insurers to reimburse for hospital charges associated with provision of dental care for children in the operating room.5 Such legislation has resulted in increased access to care, with more children receiving services in an operating room setting after enactment of legislation.23

Policy Statement

The AAPD encourages all policy makers and third-party payors to consult the AAPD in the development of benefit plans that best serve the oral health interests of infants, children, adolescents, and individuals with special health care needs. 

The AAPD strongly believes that the treating dentist determines the medical necessity for sedation/general anesthesia consistent with accepted guidelines on sedation and general anesthesia.1,7

           The AAPD strongly encourages third-party payors to:

  1.   recognize that sedation or general anesthesia is necessary to deliver compassionate, quality oral health care to some infants, children, adolescents, and persons with special health care needs. 
  2.   include sedation, general anesthesia, and related facility services as benefits of health insurance without discrimination between the medical or dental nature of the procedure.
  3.   end denial of reimbursement for sedation, general anesthesia, and facility costs related to the delivery of oral health care. 
  4.   regularly consult the AAPD and the ADA with respect to the development of benefit plans that best serve the oral health interests of infants, children, adolescents, and patients with special care  
      needs.24

The AAPD encourages all states to enact general anesthesia legislation that requires third party payors to reimburse for facility and/or anesthesia costs associated with providing oral health care for children. 

References

  1. American Academy of Pediatric Dentistry. Definition of medically-necessary care. Pediatr Dent 2016;38(special issue):15.
  2. American Academy of Pediatrics. Model contractual language for medical necessity for children. Pediatr 2005; 116(1):261-2. Reaffirmed October 2011, Available at: “http://www.pediatrics.org/cgi/doi/10.1542/96peds.2011-3210”. Accessed September 6, 2015. (Archived by WebCite® at: “http://www.webcitation.org/6fW67njQU”)
  3. Glassman P, Caputo A, Dougherty N, et al. Special Care Dentistry Association consensus statement on sedation, anesthesia, and alternative techniques for people with special needs. Spec Care Dentist 2009;29(1):2-8, quiz 67-8.
  4. White HR, Lee JY, Rozier RG. The effects of general anesthesia legislation on operating room visits by preschool children undergoing dental treatment. Pediatr Dent 2008;30(1):500-5.
  5. American Academy of Pediatric Dentistry Oral Health Policy and Research Center. Technical Report 2-2012: An Essential Health Benefit: General Anesthesia for Treatment of Early Childhood Caries. Available at: “http://www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf ”. Accessed September 7, 2015. (Archived by WebCite® at: “http://www.webcitation.org/6fXaZXBRg”)
  6. Escanilla-Casal A, Aznar-Gómez M, Viaño JM, LópezGiménez A, Rivera-Baró A. Dental treatment under general anesthesia in a group of patients with cerebral palsy and a group of healthy pediatric patients. Med Oral Patol Oral Cir Bucal 2014;19(5):e490-4.
  7. American Academy of Pediatric Dentistry. Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr Dent 2016;38(special issue):216-45. 
  8. American Academy of Pediatric Dentistry. Guideline on use of anesthesia personnel in administration of officebased deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2016;38(special issue): 246-9.
  9. White BA. The costs and consequences of neglected medically necessary oral care [review]. Spec Care Dentist 1995;15(5):180-6.
  10. Cameron CA, Litch CS, Liggett M, Heimberg S. National Alliance for Oral Health Consensus Conference on Medically-Necessary Oral Health Care: Legal issues. Spec Care Dentist 1995;15(5):192-200.
  11. Crall J. Behavior management conference Panel II report–Third party payor issues. Pediatr Dent 2004;26(2):171-4.
  12. Jankauskiene B, Narbutaite J. Changes in oral healthrelated quality of life among children following dental treatment under general anaesthesia. A systematic review. Stomatologija 2010;12(2):60-4.
  13. Jankauskiene B, Virtanen JI, Kubilius R, Narbutaite J. Oral health-related quality of life after dental general anaesthesia treatment among children: A follow-up study. BMC Oral Health 2014;14(1):1-7.
  14. . Gaynor WN, Thomson WM. Changes in young children’s OHRQoL after dental treatment under general anaesthesia. Int J Paediatr Dent 2012;22(4):258-64. 
  15. Yawary R, Anthonappa RP, Ekambaram M, McGrath C, King NM. Changes in the oral health-related quality of life in children following comprehensive oral rehabilitation under general anaesthesia. Int J Paediatr Dent 2016;26(5):322-9. 
  16. Baghdadi ZD. Children’s oral health-related quality of life and associated factors: Midterm changes after dental treatment under general anesthesia. J Clin Experimental Dent 2015;7(1):e106.
  17. Malden PE, Thomson WM, Jokovic A, Locker D. Changes in parent-assessed oral health related quality of life among young children following dental treatment under general anaesthestic. Community Dent Oral Epidemiol 2008;36(2):108-17. 
  18. Cantekin K, Yildirim MD, Cantekin I. Assessing change in quality of life and dental anxiety in young children following dental rehabilitation under general anesthesia. Pediatr Dent 2014;36(1):12E-17E. 
  19. Klaassen MA, Veerkamp JS, Hoogstraten J. Young children’s oral health-related quality of life and dental fear after treatment under general anaesthesia: A randomized controlled trial. Eur J Oral Sci 2009;117(3):273-8. 
  20. Antunes LAA, Andrade MRTC, Leão ATT, Maia LC, Luiz R. Change in the quality of life of children and adolescents younger than 14 years old after oral health interventions: A systematic review. Pediatric Dent 2013; 35(1):37-42.
  21. Cunnion DT, Spiro A, Jones JA, et al. Pediatric oral health-related quality of life improvement after treatment of early childhood caries: A prospective multisite study. J Dent Child 2010;77(1):4-11.
  22. American Dental Association. Benefits for services by qualified practitioners (1989:546). In: ADA Current Policies Adopted 1954-2013. American Dental Association. Chicago, Ill.; 2014:94.
  23. White HR, Lee JY, Rozier RG. The effects of general anesthesia legislation on operating room visits by preschool children undergoing dental treatment. Pediatr Dent 2008;30(1):500-5.
  24. American Academy of Pediatric Dentistry. Policy on model dental benefits for infants, children, adolescents, and individuals with special health care needs. Pediatr Dent 2016;38(special issue):100-2.