Sedation Dentistry and Insurance Reimbursement
November 14, 2016
By Dr. Lee Lichtenstein
Understandably, many people require some type of sedation when having dental work done. This is especially true for individuals with special needs who may have difficulty tolerating pain, understanding the procedures or expressing their concerns. Behavioral relaxation and desensitization techniques are evidence-based methods to systematically address these concerns in a compassionate and personalized way. If, however, these techniques are insufficient and the dental work is medically necessary, pharmaceutical sedation can offer a gentler alternative to physical restraint.
In addition to general anesthesia, there are several types of pharmaceutical sedation techniques available.Health plans issued in New Jersey are required by law to cover the cost when general anesthesia is required for individuals with severe disabilities.
Preparing for the Visit
It can be helpful for some individuals to tour the doctor’s office and become familiar with the environment ahead of the appointment. For example, the dentist may show the patient the different equipment such as heart rate monitor, have the patient try on the blood pressure cuff for size and even print out a blood pressure reading for the patient as a “souvenir.” Prior to the procedure, if the patient is cooperative, the dentist should perform an evaluation of the tonsils and airway to ensure that they are a good candidate for sedation.
Levels of Sedation
There are different levels of sedation (conscious and unconscious) that may be administered depending on what the caregivers and doctor have agreed upon. These are some of the possible pharmaceutical sedation methods the dentist may use:
| Nitrous Oxide and Oxygen (N2O/O2) Sedation
Nitrous oxide works very quickly, reaching the brain within 20 seconds. The depth of sedation can be altered moment to moment, allowing the person administering it to decrease or increase the level of sedation. Once switched off, the gas is eliminated from the body within 3-5 minutes. Nitrous oxide is commonly used by dentists. |
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| Oral Medication
The use of oral medications is greatly debated due to the inexact nature of this form of sedation. Because the pill or syrup must travel through the stomach and liver before entering the bloodstream, the effect that the oral medication is having on the patient may be unclear. |
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| Intravenous Sedation (IV)
Typically, the benzodiazepines midazolam and diazepam are used in IV sedation, with midazolam being the most common. IV sedation provides a more exact administering of drugs into the system because of the direct entry into the bloodstream. IV sedation offers the dentist a more accurate administering to effect ratio. |
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| General Anesthesia
The anesthesiologist may use a gas, such as sevoflurane by placing a mask over the patient’s nose and mouth. Once the patient is relaxed an IV will be inserted and the prescribed drug will begin to be administered. Because the patient is unconscious, breathing equipment may be inserted either through the mouth or the nose. Nasal intubation is preferable so that the mouth is clear for the dentist to work. In order for general anesthesia to be administered in the doctor’s office, there must be three trained dental personnel including the doctor in the room at all times, and one must be constantly documenting and monitoring vital signs. In addition, appropriate resuscitation or reversing agents and a suitable recovery area must be available in the office. |
Nitrous oxide is a clear odorless gas used as a method of conscious sedation. To be effective, nitrous oxide must be inhaled, using a mask fitted to the patient’s nose. Therefore, the patient must be old enough and cooperative enough to wear the mask as long as necessary.
The next level of conscious sedation is the use of oral medication. In dentistry the most commonly utilized medications are benzodiazepines, which work to decrease anxiety. Examples include diazepam, midazolam and lorazepam.
Intravenous (IV) sedation is the next level of conscious sedation. Typically, the patient is not aware of the procedure but is still breathing on his or her own. A very thin needle is put into a vein close to the surface of the skin in either the arm or the back of the hand and remains there throughout the procedure.
The last level, general anesthesia, or being “put to sleep” is unconscious sedation. Only an anesthesiologist can deliver general anesthesia.Insurance Reimbursement for General Anesthesia
The single most common barrier to dental treatment for people with special needs is the reluctance of health plans to include general anesthesia as a covered benefit.
In 1999, New Jersey passed legislation requiring health plans issued in the state to provide coverage for general anesthesia for dental services for children under the age of five years and for people with severe disabilities.
To help ensure that general anesthesia will be covered for a person with a disability, parents and caregivers can ask other professionals (pediatricians, neurologists, psychiatrists, etc.) to write letters of “verification of need” before treatment is done. For example, a letter can state “the individual has autism spectrum disorder and due to aggressive and uncooperative behavior in the dental office setting, requires sedation under general anesthesia in order to ensure his/her safety and that of others.”
In the event that a claim for anesthesia is denied, caregivers must assertively communicate with the insurers, including contacting the “patient advocate” (the insurance company is required to provide one) and following appeal procedures, the last of which is an external appeal submitted to the New Jersey Department of Banking and Insurance. The Department can also assist with inquiries about the law and open a formal complaint.
If you have questions about Sedation Dentistry or Insurance Coverage, please contact our Helpline at 800.4.AUTISM or information@autismnj.org
About the Author
Dr. Lee Lichtenstein is dual trained as an anesthesiologist and as a dentist. Raised in W. Long Branch, NJ, he graduated from Rensselaer Polytechnic Institute with a Bachelor of Science in Chemistry; where he was the recipient of the Williams Pitt Mason Award for Outstanding Achievement (chosen from class of 1000). He graduated from Fairleigh Dickinson University, School of Dentistry and completed his General Practice Residency Program at Middlesex General Hospital (Robert Wood Johnson Medical Center) in New Brunswick, NJ. Dr. Lichtenstein also completed the Dental Anesthesiology Residency Program at Long Island Jewish Medical Center and practiced afterwards part-time in the Operating Room at LIJMC for 14 years. Read more>>