MedicaidPrior AuthHigh impact
[Indiana] Dental Sedation Coverage Rationale and Clinical Criteria Overview
CareSource·IN · Dentistry, Oral & Maxillofacial Surgery, Pediatrics·Specialty Services
Effective date
Jan 8, 2025
We identified it
May 9, 2026
Summary
CareSource Indiana Medicaid clarifies dental sedation coverage requirements, emphasizing that the CareSource Sedation Justification Scoring Tool must be submitted for all Moderate, Deep Sedation, and General Anesthesia requests. Key restrictions include: nitrous oxide is not reimbursable with other sedation types, Deep Sedation/General Anesthesia codes are not covered for patients 21+ in office settings (with limited exceptions), IV sedation in dental offices is only reimbursable for oral surgery, and only one sedation type is allowed per day of service.
Action Required
By January 8, 2025 (effective immediately): (1) Billing team must implement requirement to obtain completed CareSource Sedation Justification Scoring Tool for all Moderate, Deep Sedation, and General Anesthesia requests before claim submission. (2) Update billing system edits to deny claims for: CPT D9222/D9223 for patients age 21+ in office-based settings (except documented exceptions); nitrous oxide (code not specified in policy) when billed with D9239, D9243, or general anesthesia codes; and more than one sedation code per day of service. (3) Providers must document medical necessity and clinical justification for all sedation requests. (4) Update billing software to restrict D9239/D9243 IV sedation billing to oral surgery services only in dental office settings. (5) Verify patient age and setting (office, ASC, hospital) before submitting sedation claims. Claims submitted without completed justification scoring tool or violating age/setting/frequency restrictions will be denied.