Prior authorization requirements for moderate to deep anesthesia for dental surgery in the facility setting

As of January 4, 2021, prior authorization (PA) requirements have changed for the following: Moderate to Deep Anesthesia for Dental Surgery in the Facility Setting (includes Hospital and Ambulatory Service Centers). The medical codes listed below will require PA by Anthem. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements shall result in denied claims.

PA requirements will be added to the following codes when K02.9 (Dental Caries, unspecified) is included as a diagnosis:

• 00170 — Anesthesia for intraoral procedures, including biopsy; not otherwise specified
• 41899 — Unlisted procedure, dentoalveolar structures (for anesthesia services billed on a facility claim listing this code as the primary procedure)
• 99151 — Moderate sedation services provided by the same physician or other qualified healthcare 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 five years of age
• 99152 — Moderate sedation services provided by the same physician or other qualified healthcare 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 five years or older
• 99153 — Moderate sedation services provided by the same physician or other qualified healthcare 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
• 99155 — Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than five years of age
• 99156 — Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age five years or older
• 99157 — Moderate sedation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time

To request PA, you may use one of the following methods:

• Web: Availity.com
• Fax: 800-964-3627
• Phone: 844-396-2330

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com by visiting https://mediproviders.anthem.com/nv > Login. Contracted and noncontracted providers who are unable to access Availity may call Provider Services at 844-396-2330 for PA requirements.