Prior Authorization : Services Requiring Prior Authorization

Inhalation of Nitrous Oxide

Coverage Policy and Prior Authorization Criteria for Members 20 Years of Age and Younger

ForwardHealth covers inhalation of nitrous oxide for members 20 years of age and younger when one of the following criteria is met:

• An emergency extraction is needed to treat infection (e.g., space infection, moderate to severe pericornitis) or after trauma.
• An extraction has been requested for the member in conjunction with ForwardHealth-approved orthodontic treatment.
• The member has been medically diagnosed with a permanent physical, developmental, or intellectual disability, or has a documented medical condition that impairs their ability to maintain oral hygiene. (Refer to Wis. Admin. Code § DHS 101.03[122m] and 101.03[41] for definitions of physical disability and developmental disability.)
• The member has been medically diagnosed with an anxiety disorder by a qualified health care professional (Anxiety disorders include, but are not limited to, panic disorders [episodic paroxysmal anxiety] without agoraphobia, generalized anxiety disorders, other mixed anxiety disorders, other specified anxiety disorders, and unspecified anxiety disorders).
• The member has documented behavioral issues or failed behavioral interventions.
• The member's third molars have diagnosed pathology.

PA is required for all providers except when the service is rendered by an oral surgeon or pediatric dentist. When requesting PA for inhalation of nitrous oxide, one of the above criteria must be indicated on the PA request form. In all cases, when inhalation of nitrous oxide is performed for members 20 years of age and younger, the provider is required to document one of the above criteria in the dental record.

ForwardHealth does not cover inhalation of nitrous oxide for the express purpose of controlling apprehension or when not medically necessary, pursuant to Wis. Admin. Code § DHS 101.03(96m).

Coverage Criteria and PA Criteria for Members 21 Years of Age and Older

ForwardHealth covers inhalation of nitrous oxide for members 21 years of age and older with PA.

When requesting PA for inhalation of nitrous oxide one of the following criteria must be indicated on the PA request form for inhalation of nitrous oxide to be approved:

• An emergency extraction is needed to treat infection (e.g., space infection, moderate to severe pericornitis) or after trauma.
• The member has been medically diagnosed with a permanent physical, developmental, or intellectual disability, or has a documented medical condition that impairs their ability to maintain oral hygiene. (Refer to Wis. Admin. Code § DHS 101.03[122m] and 101.03[41] for definitions of physical disability and developmental disability).
• The member has been medically diagnosed with an anxiety disorder by a qualified health care professional.

Up to four units of inhalation of nitrous oxide may be allowed per PA request. Providers are required to indicate if more than one unit is requested. If additional units beyond four are medically necessary, providers may submit another PA request once the original four units have been used.