CurrentBlue Cross Blue Shield - MassachusettsPolicy 154

Monitored Anesthesia Care Mac Prn

Defines medical necessity criteria, applicable CPT/ICD-10 codes, and policy history for monitored anesthesia care (MAC) in the outpatient setting for gastrointestinal endoscopic, bronchoscopy, and interventional pain procedures for Commercial and specified Medicare products. Also describes ASA classifications, sedation depth definitions, and evidence summary.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMonitored Anesthesia Care Mac Prn

Policy CodePolicy 154

Change TypeAnnual review; coding clarifications; 1/2024 revisions

Effective Date

Next Review Date

Key ActionOperating physician or anesthesiologist/CRNA must document specific risk factors or significant medical conditions that meet the medical necessity criteria for MAC.

SourceLink

POLICY UPDATE CHANGES

Policy updated with literature review through September 11, 2025; references added. Policy statements unchanged.

Coding information clarified.

Policy clarified to include ASA Physical Status Classification examples and added diagnoses codes list; enforcement update and new diagnoses-to-CPT codes edit implemented.

10Primary CPT codes listed

100+ICD-10 diagnosis codes listed

III-IV-VASA risk classes indicating increased risk

Coverage Summary

Overview: This policy addresses coverage of Monitored Anesthesia Care (MAC) for outpatient gastrointestinal endoscopic, bronchoscopy, and interventional pain procedures. It defines MAC as a specific anesthesia service provided by qualified anesthesia personnel with the ability to provide or convert to general anesthesia, and it summarizes ASA definitions of sedation depth and related guidance. The policy stance is mixed: MAC is considered medically necessary when documentation shows specific risk factors or significant medical conditions (as detailed in the criteria) but is not medically necessary for patients at low-to-average risk (for example routine screening/diagnostic colonoscopy in ASA I patients).

Effective/Last review date: Last review 2026-01-01 (policy statements current per annual review).

Surface thresholds and quick facts

BMI threshold>= 35 kg/m2

Follow-up / surveillance interval (qualifies for MAC after EMR)<= 2 years from sentinel procedure

ASA physical status classes indicating increased riskClass III, IV, or V

Primary CPT codes listed (count)10 codes listed (examples: 00520, 00732, 00813, 01936)

ICD-10 diagnosis codes listed (count)100+ codes listed (wide diagnostic list included)

Medical‑Necessity Criteria

Coding

Covered CPT codesCPTCovered

00740	Anesthesia for upper intestinal endoscopic procedures, endoscope introduced proximal to duodenum
00741	Anesthesia for lower intestine endoscopic procedures, endoscope introduced distal to duodenum
00742	Anesthesia for diagnostic or therapeutic bronchoscopy
00420	Anesthesia for procedures on esophagus
00630	Anesthesia for procedures on shoulder and axilla
99152	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, initial 15 minutes
99153	Each additional 15 minutes
99155	Moderate sedation services provided by a physician other than the physician performing the diagnostic or therapeutic service, initial 15 minutes
99156	Each additional 15 minutes

ICD-10 Diagnosis codes - CoveredICD-10Covered

F15.21	Stimulant dependence, in remission
F15.220	Stimulant dependence with intoxication, uncomplicated
G47.33	Obstructive sleep apnea (adult) (pediatric)
E66.01	Morbid (severe) obesity due to excess calories
I50.9	Heart failure, unspecified
N18.9	Chronic kidney disease, unspecified
K57.30	Diverticulosis of large intestine without perforation or abscess without bleeding

ICD-10 Diagnosis codes - NeutralICD-10

Z98.890	History of bariatric surgery
Z87.891	Personal history of nicotine dependence
F10.20	Alcohol dependence, uncomplicated

ICD-10 Diagnosis codes - Not covered / Low RiskICD-10Not Covered

Z00.00	Encounter for general adult medical examination without abnormal findings
Z12.11	Encounter for screening for malignant neoplasm of colon
R07.9	Chest pain, unspecified

Provider Actions & Billing Rules

Documentation Required

Document risk factors or significant medical conditions

Operating physician or anesthesiologist/CRNA must document specific risk factors or significant medical conditions that meet the medical necessity criteria for MAC.

Billing Rule

Append modifier KX for EMR‑follow up surveillance <=2 years

When an individual has had an endoscopic mucosal resection (EMR) and needs a follow up colonoscopy and/or esophagogastroduodenoscopy (EGD) and recurring surveillance is recommended <= two (2) years from the sentinel procedure, append modifier KX to the anesthesia code to attest that the policy requirements have been met.

Modifier KX — append to the anesthesia CPT code when follow-up surveillance after EMR is recommended ≤ 2 years.

Background & Evidence Summary

Background: Monitored Anesthesia Care (MAC) is defined as an anesthesia service characterized by the presence and role of anesthesia personnel providing pre/intra/postprocedure care and the capability to convert to general anesthesia if needed, per ASA statements. The ASA also provides specific definitions of sedation depth (minimal, moderate, deep, general anesthesia) and emphasizes that MAC describes the service and personnel rather than a particular depth of sedation.

Evidence and guidelines: Randomized trials and reviews have not shown consistent superiority of MAC over alternatives for ERCP; three RCTs comparing propofol-based MAC to general anesthesia in ERCP reported higher rates of sedation-related adverse events with MAC, and overall the evidence is insufficient to demonstrate improved net health outcome for ERCP, bronchoscopy, or interventional pain procedures. Nevertheless, national professional guidance (eg, ASA practice statements) supports use of MAC for patients with certain risk factors or significant medical conditions, and the policy therefore considers MAC medically necessary in those situations.

Definitions

Revision History

2026-01-01clarifiedLatest

Annual policy review; literature review updated through September 11, 2025 and references added; policy statements unchanged.

2025-10-01clarified

Coding information clarified; policy statements unchanged.

2024-01-01revised

Policy clarified to include ASA Physical Status Classification examples, list of risk factors/guidelines clarified, enforcement update and diagnoses codes list added; new diagnoses-to-CPT codes edit implemented; prior authorization and outpatient setting applicability clarified; effective 1/1/2024.