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Coverage criteria policies

Dental services- ambulatory hospitalization and anesthesia for dental care

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for ambulatory hospitalization and anesthesia for dental services for members age 13 years and older.

Prior authorization is not required for children under the age of 13 years.


Coverage of facility-related charges (outpatient or ambulatory facility) and anesthesia expenses associated with dental restorative care is generally covered under the medical plan subject to the indications listed below and per your plan documents.

Indications that are covered

Facility related charges and anesthesia expenses for dental procedures completed in a hospital, outpatient hospital, or ambulatory surgery center setting are covered for:

  1. Children under age 5.
  2. Children ages 5-12 – when care in dental offices has been attempted unsuccessfully and usual methods of behavior modification have not been successful
  3. Children ages 5-12 – when extensive amounts of restorative care, exceeding 4 appointments, are required.
  4. Members who are severely psychologically impaired or developmentally disabled, regardless of age.
  5. Members with a serious underlying medical condition, for whom dental treatment would create significant or undue medical risk if not completed in a hospital or ambulatory surgery center, regardless of age. Examples include but are not limited to:
    1. respiratory illnesses, such as asthma or COPD
    2. cardiac conditions, such as arrhythmias
    3. bleeding disorder
    4. severe risk of compromised airway
  6. Extensive procedures which prevent an oral surgeon from providing general anesthesia in the office setting, regardless of age.

Indications that are not covered

  1. Professional fees of a dentist or oral surgeon for dental services.
  2. Hospital charges and anesthesia for dental procedures in a hospital, ambulatory surgery center or outpatient hospital setting for any additional indication other than those outlined above.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.


  1. American Academy of Pediatric Dentistry (AAPD). Guideline on Behavior Guidance of the Pediatric Dental Patient. Adopted 1990, Last revised 2015. . Accessed on 6/26/2017.
  2. American Academy of Pediatric Dentistry (AAPD). General Anesthesia. Patient Brochure. Chicago, IL: AAPD; 2011. . Accessed on 6/26/2017.

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Policy activity

  • 01/01/1994 - Date of origin
  • 07/10/2017 - Effective date
Review date
  • 06/2018

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