The Non-Insured Health Benefits (NIHB) Program

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Sedation and General Anaesthesia Policy September 2012

Updated November 2012

1.0 General Principles

• All 90000 series codes, which include sedation, general anaesthesia and/or facility fees, require predetermination.
• The Non-Insured Health Benefits (NIHB) Program provides coverage for the following 90000 related services (including facilities, where applicable):
  • Deep sedation and general anaesthesia;
  • Moderate sedation:
    1. parenteral conscious sedation (intravenous and/or intramuscular);
    2. combined technique of inhalation plus intravenous and/or intramuscular injection; and
    3. nitrous oxide with oral sedation (multiple sedative drugs);
  • Minimal sedation:
    1. oral sedation;
    2. nitrous oxide; and
    3. nitrous oxide with oral sedation (single sedative drug).
• All sedation codes include the cost of sedation medication.
• Providers must adhere to the conditions of licensing, certification, accreditation and registration as per provincial/territorial and/or dental regulations to submit a claim to the NIHB Program.
• If provinces/territories provide and cover general anaesthesia and deep sedation for dental services to residents at no charge through their provincial/territorial health care insurance plan, social programs, publicly funded programs, NIHB will not cover these benefits provided in any facility. Clients under the NIHB Program will be expected to access these dental services through their provincial/territorial health care insurance plan, social program, publicly funded program or private insurance plan.

1.1 Utilization of Private Facilities

• NIHB will not provide coverage for the use of private facilities if the client has coverage for this under their private insurance plan, provincial/territorial health care insurance plan, social program or other publicly funded program. If clients choose to use a private facility, they will be responsible for the costs incurred.
• The NIHB Program may consider coverage for the use of a private facility on an exception basis, subject to the Program criteria and guidelines and unique regional, provincial/territorial circumstances.  If NIHB is to assume any financial costs, predetermination must be obtained prior to the dental services being rendered.

2.0 Predetermination Documentation Requirements for Sedation and General Anaesthesia

The NIHB Program requires the following documentation for the review of a sedation/general anaesthesia predetermination request:

• Predetermination request on one of the following forms: Complete Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29).
• Comprehensive treatment plan from the treating and/or referring dentist/specialist indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic, and surgical services.
• Rationale and/or documents to support the request for sedation or general anaesthesia. Please refer to specific eligibility criteria for each method of sedation.
• Current conventional or digital radiographs (within the last twelve months).
  1. Preoperative periapical and bitewing radiographs (if preoperative radiographs cannot be taken due to uncooperative behaviour, perioperative or postoperative radiographs must be submitted):
     • must be of good diagnostic quality (e.g., size, resolution, contrast); and
     • must be mounted and labelled with the date of service, client name and provider name.
  2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs.

Please note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

• Notation of missing teeth.
• At Health Canada's request, other documentation may be required.

3.0 General Anaesthesia and Deep Sedation

3.1 General Principles

• A frequency limitation of once in any twelve (12) month period applies.
• The NIHB Program will cover up to a regional maximum dollar value of general anaesthesia/deep sedation and facility fees in any 12 month period.
• To limit the associated risks with repeat general anaesthesia and deep sedation, dental providers should ensure, where possible, that all dental services performed under general anaesthesia and deep sedation are completed in one session.
• If multiple appointments are required, providers must submit a predetermination request along with a comprehensive treatment plan and supporting documentation (please see section 2.0., for the complete list) prior to the initiation of the treatment.
  
  Please note:  Stainless steel crowns and plastic crowns should be considered for:
  • high caries risk clients under the age of four;
  • restoration of primary molars and anterior teeth with two or more carious surfaces; and/or
  • restoration of primary molars following a pulpotomy or pulpectomy.
• Providers must ensure that other adjunctive services such as minimal or moderate sedation have been considered prior to requesting general anaesthesia or deep sedation.

3.2 Coverage eligibility for clients under 12 years of age

To be eligible for coverage for general anaesthesia or deep sedation, clients under 12 years of age must have:

• complex or extensive treatment needs; and
• all deciduous teeth should be erupted;
  and
• severe age related behaviour management limitations; or
• a significant medical condition or physical impairment.

Please note: If there are unerupted deciduous teeth present in the mouth please contact your respective dental predetermination office to discuss the predetermination request prior to proceeding with treatment.

3.3 Coverage eligibility for clients 12 years of age and older

General anaesthesia and deep sedation are not covered for the management of dental anxiety.

To be eligible for coverage for general anaesthesia or deep sedation, clients 12 years of age and older must:

• require significant surgical procedures^{Footnote 1} that are medically necessary; or
• have a significant medical condition or physical impairment.

4.0 Moderate Sedation

4.1 General Principles

• A frequency limitation of once in any twelve (12) month period applies.
• The NIHB Program will cover up to a regional maximum dollar value of moderate sedation modalities in any 12 month period.
• Applies to parenteral sedation, combined technique of inhalation plus intravenous and/or intramuscular injection, and nitrous oxide combined with oral sedative drugs.
• To limit the associated risks with repeat moderate sedation, dental providers should ensure, where possible, that all dental services performed under moderate sedation are completed in one session.
• If multiple appointments are required, providers must submit a predetermination request along with a comprehensive treatment plan and supporting documentation (please see section 2.0., for the complete list) prior to the initiation of the treatment.
• Providers must also ensure that other adjunctive services such as minimal sedation have been considered prior to requesting moderate sedation.

4.2 Coverage eligibility for clients under 12 years of age

To be eligible for coverage for moderate sedation, clients under 12 years of age must have:

• severe age related behaviour management limitations; or
• a significant medical condition or physical impairment;
  and
• complex or extensive treatment needs.

4.3 Coverage eligibility for clients 12 years of age and older

Moderate sedation is not covered for the management of dental anxiety.

To be eligible for coverage for moderate sedation, clients 12 years of age and older must:

• require significant surgical procedures^{Footnote 2} that are medically necessary; or
• have a significant medical condition or physical impairment and require complex or extensive treatment.

5.0 Minimal Sedation

5.1 General Principles

• The NIHB Program will cover up to a regional maximum dollar value of minimal sedation in any 12 month period.
• Applies to nitrous oxide, a single oral sedative drug, or a combination of nitrous oxide/oxygen and a single sedative drug.

5.2 Coverage eligibility for clients under 12 years of age

To be eligible for coverage for minimal sedation, clients under 12 years of age must have:

• severe age related behaviour management limitations;
• a significant medical condition or physical impairment;
• complex or extensive treatment needs; or
• a strong gag reflex that prevents dental care.

5.3 Coverage eligibility for clients 12 years of age and older

Minimal sedation is not covered for the management of dental anxiety, however it may be considered for the management of a documented dental phobia^{Footnote 3}.

To be eligible for coverage for minimal sedation, clients 12 years of age and older must:

• require significant surgical procedures that are medically necessary; or
• have a significant medical condition or physical impairment.