CurrentBlue Cross Blue Shield of VermontPolicy 7.02.VT01

Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

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This policy governs when monitored anesthesia care (MAC) may be medically necessary for outpatient gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures. It applies to providers documenting patient-specific risk factors, procedure characteristics, and applicable anesthesia services.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyMonitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

Policy CodePolicy 7.02.VT01

Change TypeMaterial revision

Effective DateOct 1, 2025

Last ReviewJun 1, 2025

Next Review DateJun 1, 2026

Key ActionObtain prior approval for anesthesia associated with lumbar puncture, upper or lower gastrointestinal endoscopy, combined endoscopy, and qualifying interventional pain procedures.

SourceLink

POLICY UPDATE CHANGES

The June 2025 policy update added or clarified several comorbidity categories that may support MAC, including infectious, cardiometabolic, hepato-renal, digestive, central neurologic, and psychiatric conditions.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentBlue Cross Blue Shield of VermontPolicy 7.02.VT01

Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

Customize your policy alerts

Sign up for bcbsvermont Policy 7.02.VT01 alerts

Get alerted when Policy 7.02.VT01 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyMonitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

Policy CodePolicy 7.02.VT01

Change TypeMaterial revision

Effective DateOct 1, 2025

Last ReviewJun 1, 2025

Next Review DateJun 1, 2026

Key ActionObtain prior approval for anesthesia associated with lumbar puncture, upper or lower gastrointestinal endoscopy, combined endoscopy, and qualifying interventional pain procedures.

SourceLink

POLICY UPDATE CHANGES

3Procedure categories addressed

BMI >40Morbid-obesity threshold

ASA III+Severe-comorbidity threshold

>30 minProlonged endoscopy threshold

60 minAccess exception

7Listed anesthesia codes

When Monitored Anesthesia Care May Be Covered

When MAC may be medically necessary

MAC may be considered medically necessary for gastrointestinal endoscopy, bronchoscopy, or interventional pain procedures when the proceduralist and anesthesiologist document at least one qualifying risk factor, significant medical condition, or procedure-related indication.

Qualifying patient or procedure factor

Patient risk factors or clinical conditions
- Comorbidity or procedural risk: Severe comorbidity with ASA III or greater; morbid obesity with BMI >40; documented sleep apnea; relevant infectious, cardiometabolic, hepato-renal, digestive, central neurologic, or psychiatric comorbidity; coagulopathy or bleeding disorder; prior bariatric or esophageal surgery; inability to follow simple commands; spasticity or movement disorder; history or anticipated intolerance to standard sedatives; prior procedural complication or intolerance requiring MAC; active or historical alcohol or substance use expected to necessitate MAC; age younger than 18 years or 70 years or older; or pregnancy.ASA III or greater; BMI >40; age <18 or >=70
  Examples of relevant comorbidities include diabetes, hypertension, arrhythmia, chronic renal failure, liver disease, dysphagia, inflammatory bowel disease, gastroparesis, painful anorectal conditions, prior colon surgery, epilepsy, and phobia.
- Airway obstruction risk: Increased risk for airway obstruction due to anatomic variation, including stridor; dysmorphic facial features such as Pierre-Robin syndrome or Trisomy 21; oral abnormalities; neck abnormalities; or jaw abnormalities.Adult oral opening <3 cm or adult hyoid-mental distance <3 cm may be relevant findings
  Mallampati score alone does not establish the need for MAC.
- Behavioral or cooperation risk: The patient is acutely agitated or uncooperative.
Procedure-related indication: The gastrointestinal endoscopy is prolonged or therapeutic and requires deep sedation.>30 minutes for examples of prolonged procedures
Examples include adhesions or strictures, ERCP, esophageal ultrasound, numerous large polyps, upper-GI stent placement, and complex therapeutic procedures.
Preventive-access exception: MAC is the only form of anesthesia offered within a 60-minute drive of the member's home.Within 60 minutes
This exception is allowed to support access to appropriate preventive services.

Not medically necessary for average-risk patients

MAC is not medically necessary when the patient is at average risk related to anesthesia and sedation.

Average-risk exclusion: The procedure is a gastrointestinal endoscopic, bronchoscopic, or interventional pain procedure and the patient is at average risk related to anesthesia and sedation.

Monitored anesthesia care (MAC) may be considered medically necessary for outpatient gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures when the proceduralist and anesthesiologist document at least one qualifying patient risk factor, significant medical condition, or procedure-related indication. Supporting circumstances may include severe comorbidity, ASA III or greater, morbid obesity with BMI >40, sleep apnea, airway-obstruction risk, behavioral or cooperation concerns, relevant comorbidities, or a prolonged or therapeutic endoscopy requiring deep sedation. An access exception may apply when MAC is the only anesthesia option available within 60 minutes of the member’s home.

MAC is considered not medically necessary for gastrointestinal endoscopic, bronchoscopic, or interventional pain procedures when the patient is at average risk related to anesthesia and sedation.

Codes and Qualifying Circumstances

Covered CPT Codes — prior approval not requiredCPTCovered

00520

Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified.

Covered CPT Codes — prior approval requiredCPTCovered

00635	Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture.
00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified.
00732	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde.
00811	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified.
00812	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy.
00813	Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum.
01991	Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position.
01992	Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position.

Informational ModifierModifier

-QS	Monitored anesthesiology care services; modifier must be reported when monitored anesthesia care services are provided. Informational.

Informational HCPCS Code — not reimbursableHCPCS

G9654

Monitored Anesthesia Care (MAC). Informational and not reimbursable.

Referenced Anesthesia Add-on CodeCPT

99100

Anesthesia for patient of extreme age, younger than 1 year and older than 70; list separately in addition to code for primary anesthesia procedure.

Morbid obesity

ThresholdBody mass index (BMI) greater than 40

Risk categoryMorbid obesity may increase the risk of complications related to anesthesia and sedation

Coverage contextMorbid obesity is a patient-specific factor that may support consideration of monitored anesthesia care (MAC)

Small adult oral opening

ThresholdAdult oral opening less than 3 cm

Risk categoryA small adult oral opening is an anatomic variation associated with increased risk for airway obstruction

Authorization, Documentation, and Audit Requirements

Prior Authorization

Prior Approval Required: Lumbar Puncture Anesthesia

Prior approval is required for anesthesia for diagnostic or therapeutic lumbar puncture procedures.

CPT 00635 — anesthesia for procedures in the lumbar region; diagnostic or therapeutic lumbar puncture

Prior Authorization

Prior Approval Required: Upper GI Endoscopy Anesthesia

Prior approval is required for anesthesia for upper gastrointestinal endoscopic procedures, including endoscopic retrograde procedures.

CPT 00731 — upper GI endoscopic procedures, endoscope introduced proximal to the duodenum
CPT 00732 — upper GI endoscopic retrograde procedures

Policy Background

Monitored anesthesia care (MAC) is a physician anesthesia service defined by the presence and capabilities of qualified anesthesia personnel, rather than by a particular level of sedation. It includes preprocedure assessment and optimization, intraprocedure monitoring and treatment, postprocedure management, airway management, and readiness to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the care is considered general anesthesia, whether or not airway instrumentation is used.

Key Definitions

Monitored anesthesia care (MAC)

Service definitionMAC is a specific anesthesia service for a diagnostic or therapeutic procedure, not a particular level of sedation

Pre-procedureIncludes preprocedure assessment and optimization of patient comorbidity and periprocedural risk

Intra-procedureIncludes continuous monitoring, diagnosis and treatment of clinical problems, support of vital functions, and administration of medications as necessary for patient safety

Post-procedureIncludes postprocedure anesthesia management and other medical services needed to complete the procedure safely

Required capabilityQualified anesthesia personnel must be prepared to manage the airway and convert to general anesthesia when necessary

ASA Physical Status Classification System

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyMonitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

Policy CodePolicy 7.02.VT01

Change TypeMaterial revision

Effective DateOct 1, 2025

Last ReviewJun 1, 2025

Next Review DateJun 1, 2026

Key ActionObtain prior approval for anesthesia associated with lumbar puncture, upper or lower gastrointestinal endoscopy, combined endoscopy, and qualifying interventional pain procedures.

SourceLink

On This Page

Coverage contextThis finding may support consideration of MAC when documented with the patient's airway-risk assessment

Decreased adult hyoid-mental distance

ThresholdAdult hyoid-mental distance less than 3 cm

Risk categoryA decreased hyoid-mental distance is an anatomic variation associated with increased risk for airway obstruction

Coverage contextThis finding may support consideration of MAC when documented with the patient's airway-risk assessment

Prolonged endoscopy

ThresholdGreater than 30 minutes

Procedure typeProlonged gastrointestinal endoscopy may require deep sedation

ExamplesExamples include adhesions or strictures, ERCP, esophageal ultrasound, numerous large polyps, upper-GI stent placement, and complex therapeutic procedures

Large polyp history

HistoryRemoval of numerous large polyps

Polyp sizeAt least 10 mm in diameter

Coverage contextThis history is an example of a prolonged or therapeutic endoscopy circumstance that may require deep sedation

Extreme age

Younger patientsYounger than 18 years

Older patients70 years or older

Coverage contextAge younger than 18 years or 70 years or older is a patient-specific factor that may support consideration of MAC

Access exception

Access conditionMAC is the only form of anesthesia offered within a 60-minute drive of the member's home

PurposeThe exception supports access to appropriate preventive services

ApplicabilityMAC may be allowed when the 60-minute access condition is met

Prior Authorization

Prior Approval Required: Lower or Combined GI Endoscopy Anesthesia

Prior approval is required for anesthesia for lower intestinal, screening colonoscopy, and combined upper and lower gastrointestinal endoscopic procedures.

CPT 00811 — lower intestinal endoscopic procedures
CPT 00812 — screening colonoscopy
CPT 00813 — combined upper and lower GI endoscopic procedures

Prior Authorization

Prior Approval Required: Interventional Pain Anesthesia

Prior approval is required for anesthesia for qualifying diagnostic or therapeutic nerve blocks and injections, whether performed in the prone or non-prone position.

CPT 01991 — nerve blocks and injections other than in the prone position
CPT 01992 — nerve blocks and injections in the prone position

Documentation Required

Document Qualifying Risk Factors

When requesting or billing monitored anesthesia care for gastrointestinal endoscopy, bronchoscopy, or interventional pain procedures, the proceduralist and anesthesiologist must document patient-specific risk factors or significant medical conditions supporting medical necessity.

Severe comorbidity (ASA III or greater); morbid obesity (BMI >40); documented sleep apnea; or relevant infectious, cardiometabolic, hepato-renal, digestive, central neurologic, or psychiatric conditions, including diabetes, hypertension, arrhythmia, chronic renal failure, liver disease, dysphagia, inflammatory bowel disease, gastroparesis, painful anorectal conditions, prior colon surgery, epilepsy, or phobia
Coagulopathy or bleeding disorder; prior bariatric or esophageal surgery; inability to follow simple commands from cognitive dysfunction, intoxication, or psychological impairment; spasticity or movement disorder; or acute agitation or uncooperative behavior
Expected intolerance to standard sedatives, including chronic opioid or benzodiazepine use; prior procedural complication or intolerance requiring MAC; or active or historical alcohol or substance use expected to necessitate MAC
Age younger than 18 or 70 years or older, pregnancy, or increased airway-obstruction risk from stridor, dysmorphic facial features, oral, neck, or jaw abnormalities
Prolonged or therapeutic GI endoscopy requiring deep sedation; MAC may also be allowed when it is the only anesthesia option within a 60-minute drive of the member’s home

Documentation Required

Document Airway Assessment

Document the preoperative airway assessment when airway obstruction or difficult intubation risk is relevant. Mallampati Class 3 or 4 indicates higher intubation difficulty risk, but the Mallampati score alone does not establish the need for monitored anesthesia care.

Record the Mallampati assessment and other relevant airway findings
Consider additional airway assessments, including the upper-lip-bite test, intubation difficulty scale, and Cormack-Lehane grading system

Documentation Required

Document Qualified Anesthesia Capability

MAC must be provided by qualified anesthesia personnel with training and experience to assess the patient, continuously evaluate and monitor physiologic functions, and diagnose and treat pharmacologic and non-pharmacologic deviations. The provider must be prepared and qualified to manage airway and hemodynamic issues and convert to general anesthesia when necessary.

Complete preprocedure assessment and optimization, intraprocedure monitoring and management, and postprocedure anesthesia care
Support vital functions, administer medications as needed for safety, and diagnose and treat clinical problems during the procedure
Be prepared to convert to general anesthesia if the patient loses consciousness and the ability to respond purposefully

Denial Risk

Average-Risk Patient: MAC Not Medically Necessary

MAC is not medically necessary for covered gastrointestinal endoscopic, bronchoscopic, or interventional pain procedures when the patient is at average risk related to anesthesia and sedation.

Medical necessity requires documented qualifying risk factors, significant medical conditions, or another policy-supported circumstance

Denial Risk

Insufficient Medical-Necessity Documentation

Medical-necessity documentation must identify the specific patient risks or significant medical conditions supporting MAC; general statements that anesthesia is preferred are insufficient.

Specify the applicable comorbidities, prior anesthesia or procedural intolerance, medication tolerance issues, age, pregnancy, behavioral or cognitive concerns, airway findings, or procedural complexity
For airway risk, include relevant findings and explain how the combined assessment supports MAC; Mallampati score alone is not sufficient
Document qualifying prolonged or therapeutic endoscopy requiring deep sedation when applicable

Denial Risk

Required Prior Approval Not Obtained

Obtain required prior approval before submitting claims for the listed anesthesia services. Failure to obtain authorization may result in denial or payment impact under the policy.

Prior approval required for CPT 00635, 00731, 00732, 00811, 00812, 00813, 01991, and 01992
Modifier -QS must be reported when monitored anesthesia care services are provided
CPT 00520 does not require prior approval; HCPCS G9654 is informational and not reimbursable

Denial Risk

Audit Noncompliance

Blue Cross VT may audit any provider or facility for compliance with the medical policy. If an audit identifies non-compliance, Blue Cross VT may recoup all non-compliant payments.

Maintain documentation supporting medical necessity, qualified anesthesia capability, and required authorization
Ensure billed services and reported modifiers comply with the policy and coding instructions

ASA IA normal, healthy patient

ASA IIA patient with mild systemic disease

ASA IIIA patient with severe systemic disease

ASA IVA patient with severe systemic disease that is a constant threat to life

ASA VA moribund patient who is not expected to survive without the operation

Mallampati score

Class 1The tonsils, uvula, and soft palate are fully visible

Class 2The hard and soft palate, uvula, and upper portion of the tonsils are visible

Class 3The hard and soft palate and the base of the uvula are visible

Class 4Only the hard palate is visible

SignificanceClasses 3 and 4 indicate higher risk of intubation difficulty; the Mallampati score alone does not determine the need for MAC