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CareSourceMedicaid · Prior Auth · Specialty Services · IN · Dentistry, Oral & Maxillofacial Surgery, PediatricsHigh impact

[Indiana] Dental Sedation Coverage Rationale and Clinical Criteria Overview

Act
by Jan 8, 2025 (effective immediately)
Effective date
Jan 8, 2025
Identified
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.

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What to do

by Jan 8, 2025 (effective immediately) · 6 steps
01Billing team must implement requirement to obtain completed CareSource Sedation Justification Scoring Tool for all Moderate, Deep Sedation, and General Anesthesia requests before claim submission.
02Update 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.
03Providers must document medical necessity and clinical justification for all sedation requests.
04Update billing software to restrict D9239/D9243 IV sedation billing to oral surgery services only in dental office settings.
05Verify patient age and setting (office, ASC, hospital) before submitting sedation claims.
06Claims submitted without completed justification scoring tool or violating age/setting/frequency restrictions will be denied.

Codes mentioned

D9222D9223D9239D9243

Original notice

[Indiana] Dental Sedation Coverage Rationale and Clinical Criteria Overview
caresource.com · Always check the source before changing claims.
View original ↗

Related changes

See all CareSource changes →
[Georgia] SKYGEN PoliciesMediumEffective Nov 1, 2025 · Provider Bulletin[Indiana] Updated Dental Sedation Coverage Rationale and Clinical Criteria OverviewMediumEffective Jan 1, 2025 · Specialty ServicesBrowse every CareSource change in the policy list

Related policy hubs

CareSource policiesIN policy changesDentistryOral & Maxillofacial SurgeryPediatricsCode D9222Code D9223Code D9239Code D9243

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