To help participating dentists when submitting claims for general anesthesia and sedation, the following summary is intended as a reminder of current requirements. Delta Dental of Virginia's criteria for general anesthesia and sedation follow Delta Dental Plan Association national processing policies, and are also provided in the Delta Dental Dentist Handbook.
- Benefits are provided for covered surgical procedures for up to one hour for both children and adults.
- Benefits are also provided in cases of concurrent medical conditions, an example of which might be a patient with special health care needs.
For anesthesia or sedation services that exceed one hour, Delta Dental, consistent with national processing policies, requires documentation in the form of a narrative and anesthesia record, documenting why the additional time was needed. The lack of needed documentation could result in a denial for information. In the case of a pre-determination, where the need for anesthesia is anticipated to exceed an hour, please include the needed documentation for these services as well.
If you disagree with a decision on a claim or a pre-determination, the recommendation is to file a written appeal, (or second-level appeal if the first appeal has been denied). Please be sure to provide additional information that might conceivably lead to a different outcome. This might include additional radiographs, chart notes, photos as appropriate, or a more detailed narrative explaining the circumstances in more detail and why you believe the submission should be approved. The additional information will lead to a speedier outcome and will help to improve communication between your office and Delta Dental of Virginia.
Michael D Weitzner, DMD, MS
Dental Director, Delta Dental of Virginia
