CurrentBlue Cross Blue Shield - MassachusettsPolicy 154

Monitored Anesthesia Care (MAC) for outpatient endoscopy, bronchoscopy, and interventional pain procedures

Defines medical necessity criteria for monitored anesthesia care (MAC) in the outpatient setting for gastrointestinal endoscopic, bronchoscopy, and interventional pain procedures for Commercial and Medicare members; lists risk factors/medical conditions that make MAC medically necessary, situations where MAC is not medically necessary, CPT codes affected, and a long ICD-10 diagnosis code list applicable when criteria are met.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMonitored Anesthesia Care (MAC) for outpatient endoscopy, bronchoscopy, and interventional pain procedures

Policy CodePolicy 154

Change TypeAnnual review; coding/clarifications

Effective DateFeb 1, 2010

Next Review Date

Key ActionOperating physician or anesthesiologist/CRNA must document specific risk factors or significant medical conditions that justify MAC for coverage.

POLICY UPDATE CHANGES

Policy updated with literature review through September 30, 2024; policy statements unchanged.

Coding information clarified and diagnoses codes list added effective 1/1/2024.

American Society of Anesthesiology (ASA) Physical Status Classification examples added and list of risk factors clarified.

154Policy Number

MultipleCPT codes covered (listed)

ExtensiveICD-10 diagnosis codes listed

Coverage Summary

Monitored Anesthesia Care (MAC) is a defined anesthesia service provided in the outpatient setting for gastrointestinal endoscopic, bronchoscopy, and interventional pain procedures; it is defined by the anesthesia personnel present and encompasses preprocedure, intraprocedure, and postprocedure anesthesia management, with providers required to be prepared to convert to general anesthesia when necessary. (Policy applies to Commercial and Medicare members.)

Scope: This policy defines medical necessity criteria for MAC in outpatient GI endoscopic, bronchoscopy, and interventional pain procedures for Commercial and Medicare members, lists risk factors/medical conditions that make MAC medically necessary, specifies situations where MAC is not medically necessary, and identifies CPT and ICD-10 codes affected. Status: CURRENT. Effective date: 2010-02-01 (policy number 154; enforcement/clarifications effective 1/1/2024); last review: 2025-01-01.

Thresholds and Quick Facts

Policy number154

Effective date2010-02-01

Last review2025-01-01

Threshold - Severe obesityBMI ≥ 35 kg/m2

Threshold - Follow-up surveillance interval≤ 2 years from sentinel procedure

Scope summaryDefines medical necessity criteria for monitored anesthesia care (MAC) in the outpatient setting for GI endoscopic, bronchoscopy, and interventional pain procedures; lists risk factors/medical conditions making MAC medically necessary, situations where MAC is not medically necessary, CPT codes affected, and extensive ICD-10 diagnosis code list when criteria met.

Medical-Necessity Criteria

Medically Necessary - Follow-up/Surveillance Endoscopy within 2 years

MAC may be considered MEDICALLY NECESSARY for GI endoscopic and bronchoscopy procedures when operating physician/anesthesiologist documents that a follow-up procedure or recurring surveillance is recommended within 2 years from the sentinel procedure as supported by professional society guidelines (examples provided).

Follow-up/Surveillance Requirement: Follow-up or recurring cadence of interval surveillance endoscopic procedure recommended ≤ 2 years from sentinel procedure≤ 2 years from sentinel procedure

Examples include surveillance after EMR of polyps and high‑risk/genetic syndrome screening (Lynch, Serrated Polyposis, FAP, Attenuated FAP, Juvenile Polyposis, Peutz‑Jeghers). Recommendation supported by professional society guidelines.

Coding

CPT codes requiring medical necessity criteria to be met for coverageCPTCovered

00740	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
00741	Anesthesia for upper gastrointestinal endoscopic procedures; endoscope introduced distal to duodenum
00810	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
00734	Anesthesia for procedures on the stomach, laparoscopic

ICD-10 diagnosis codes considered medically necessary when submitted with the CPT codes aboveICD-10Covered

C79.89	Secondary malignant neoplasm of other specified sites
D13.91	Benign neoplasm of colon, unspecified
D48.7	Neoplasm of uncertain behavior of other specified sites
D57.01	Sickle-cell anemia with crisis, unspecified
D57.03	Sickle-cell disease with splenic sequestration
D57.04	Sickle-cell thalassemia with crisis
D57.09	Other sickle-cell disorders with crisis
D57.211	Hb-SS disease with acute chest syndrome
D57.213	Hb-SS disease with splenic sequestration
D57.411	Sickle-cell thalassemia with acute chest syndrome

1–10 of 109

1/11

ICD-10 neutralICD-10

031.00X1	Primary tuberculosis of lung, bacteriological or histological confirmation, pulmonary, initial encounter
031.10X0	Primary tuberculosis of larynx, unspecified encounter
031.11X0	Primary tuberculosis of larynx, subsequent encounter
031.20X0	Primary tuberculosis of ear, unspecified encounter
031.20X2	Primary tuberculosis of ear, with other specified encounter
031.30X0	Primary tuberculosis of other respiratory organs, unspecified encounter
032.1XX0	Tuberculosis of respiratory system, other
032.2XX0	Tuberculosis of nervous system
032.3XX0	Tuberculosis of intestines
032.4XX0	Tuberculosis of genitourinary system

1–10 of 18

1/2

ICD-10 neutralICD-10

No codes listed

Provider Actions & Billing Rules

Documentation Required

Operating physician/anesthesiologist documentation of risk factors

Operating physician or anesthesiologist/CRNA must document specific risk factors or significant medical conditions that justify MAC for coverage.

Billing Rule

Append modifier KX for surveillance within 2 years

When follow-up or recurring surveillance endoscopy is recommended ≤ 2 years from the sentinel procedure, append modifier KX to the anesthesia code to attest that the policy requirements have been met.

Examples include surveillance after EMR of polyps (EMR) as noted in examples for surveillance indications.

Background & Evidence

Definition: Monitored Anesthesia Care (MAC) is a specific anesthesia service defined by the type of anesthesia personnel present during a procedure (not solely by level of sedation). MAC includes the capability to convert to general/regional anesthetic and comprises diagnosis and treatment of clinical problems during the procedure, administration of sedatives/analgesics/anesthetic agents as needed, support for vital functions, and postprocedure anesthesia management. The provider must be prepared and qualified to convert to general anesthesia if the patient loses protective airway reflexes or becomes unresponsive.

Guidance and evidence: The American Society of Anesthesiologists (ASA) definitions and practice statements are cited as national guidance distinguishing MAC from moderate sedation and outlining monitoring and readiness to manage deeper levels of sedation (including conversion to general anesthesia). While national guidelines support use of MAC for patients with certain risk factors or significant medical conditions undergoing outpatient procedures, the evidence is limited in some settings — for example, systematic reviews and RCTs of MAC versus general anesthesia in ERCP reported few differences overall and some RCTs found higher rates of sedation-related adverse events with propofol-based MAC. For bronchoscopy and interventional pain procedures there is a lack of published comparative evidence; national ASA guidance supports MAC in high-risk patients. The policy emphasizes that locations providing MAC must have appropriate monitoring and resuscitation capability and that personnel be able to rescue patients whose sedation becomes deeper than intended.

Evidence - Key Metrics

Literature review end dateSeptember 30, 2024

Key RCT finding

Definitions

Term	Definition
Monitored Anesthesia Care (MAC)	A specific anesthesia service for diagnostic or therapeutic procedures defined by the type of anesthesia personnel present; includes capability to convert to general/regional anesthetic and management of intra-procedure events. Includes preprocedure screening/visit, intraprocedure care, and postprocedure anesthesia management; provider must be prepared and qualified to convert to general anesthesia when necessary.
ASA Physical Status Classification	Classification system (I–VI) describing overall preoperative health/risk with examples for each class provided in policy (ASA I = normal healthy patient; ASA III–V describe increasing severity of systemic disease and risk).
ASA	American Society of Anesthesiologists (professional organization referenced for MAC definitions, monitoring standards, and guidance).

Revision History

2025-01-01annual_reviewLatest

Annual policy review. Policy updated with literature review through September 30, 2024; policy statements unchanged. (Annual review entry)

2024-10-01coding_update

Coding information clarified and diagnosis codes list added effective 1/1/2024. (Enforcement and coding clarification)

2024-01-01clarification

Policy clarified: ASA Physical Status Classification examples added and list of risk factors clarified; enforcement update; clarified prior authorization information and that policy applies to outpatient procedures. Effective 1/1/2024.