Anesthesia is used to create a loss of sensation and consciousness through the administration of one or more agents that block the transmittal of pain impulses along nerve pathways to the brain.

Effective July 5, 2012, P.L. 916, Pennsylvania Act 94, Children and Developmentally Disabled Patient Access to Quality Dental Care Act, required insurance coverage for general anesthesia and associated medical costs when provided for eligible dental patients. 

Eligible dental patient - a patient who is seven years of age or younger or developmentally disabled for whom a successful result cannot be expected for treatment under local anesthesia and for whom a superior result can be expected for treatment under general anesthesia.

Coverage under this act shall be subject to deductible, copayment or coinsurance provisions and any other general exclusions, limitations or requirements of a health insurance policy.

Anesthesia services may be considered medically necessary when performed in conjunction with other covered services.

When a claim is received for anesthesia services which are provided in conjunction with non-covered services, the physician's charge for the anesthesia service is not covered, except for the following criteria:

• Anesthesia services rendered in conjunction with routine non-covered dental procedures and bony impacted wisdom teeth may be considered medically necessary for children and special needs individuals for EITHER of  the following criteria which must be verified by appropriate medical documentation: 
  • The individual is seven (7) years of age or younger or is developmentally disabled; and 
    • A successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual or other medically compromising condition; and
    • A superior result can be expected from dental care provided under general anesthesia; or
  • The individual is twelve years of age or younger; and
    • Has documented phobias; or
    • Documented mental illness; and
    • Has dental needs of such magnitude that treatment should not be delayed or deferred;  and
    • Lack of treatment can be expected to result in infection, loss of teeth or other increased oral or dental morbidity;  and
    • A successful result cannot be expected from dental care provided under local anesthesia because of such condition;  and
    • A superior result can be expected from dental care provided under general anesthesia. 
• Monitored Anesthesia Care (MAC)/general anesthesia and associated facility charges may be considered medically necessary in conjunction with dental surgery or procedures performed by a dentist, oral surgeon or oral maxillofacial surgeon when it meets the above criteria and there is an appropriately trained and licensed professional to both administer and monitor MAC/general anesthesia in EITHER of the following locations:
  • A properly-equipped and staffed office or clinic; or
  • A hospital or outpatient surgery center.