CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

2023 Monitored Anesthesia Care For Gastrointestinal Endoscopic Procedures

Defines coverage policy for monitored anesthesia care (MAC) for outpatient gastrointestinal diagnostic and therapeutic endoscopic procedures (upper and lower endoscopy) for Medicare Advantage and commercial members, including indications when MAC is considered appropriate, documentation and audit rights, and covered CPT anesthesia codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policy2023 Monitored Anesthesia Care For Gastrointestinal Endoscopic Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review Date

Key ActionDocument in the member's medical records that MAC is medically necessary for the care provided and make documentation available for BCBSRI audit upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this update.

5+Example appropriate indications listed

5Covered CPT codes listed

NoPrior authorization required?

Coverage Summary

Scope: Defines coverage policy for Monitored Anesthesia Care (MAC) for outpatient gastrointestinal diagnostic and therapeutic endoscopic procedures (upper and lower endoscopy) for Medicare Advantage and Commercial members. Coverage is covered_with_criteria — MAC is covered when criteria in the policy are met.

Coverage Criteria - When MAC Is Appropriate

Coverage Criteria - When MAC is appropriate

Use of monitored anesthesia care for upper or lower gastrointestinal (GI) endoscopy is considered appropriate in the following circumstances:

ANY of the following

age/pregnancy
- Member is under 18 years of age
- Member is over 70 years of age
- Member is pregnant
- Member is acutely agitated and/or uncooperative
- Increased risk for complications due to severe comorbidity (ASA class III, IV, or V)ASA III, IV, or V
Increased risk for airway obstruction due to anatomic variation — any of the following
- History of stridor
- Dysmorphic facial features
- Oral abnormalities (e.g. macroglossia)
- Neck abnormalities (e.g. neck mass)
- Jaw abnormalities (e.g. micrognathia)
Prolonged or therapeutic GI endoscopy procedures requiring deep sedation — examples
- Endoscopy in members with adhesions after abdominal surgery
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Stent placement in the upper gastrointestinal tract
- Complex therapeutic procedures, such as plication of the cardioesophageal junction
Patient-specific factors increasing need for MAC
- History of adverse reaction to sedation
- History of inadequate response to sedation
- History or anticipated intolerance to standard sedatives — any of
  - Chronic opioid use
  - Chronic benzodiazepine use
- Documented sleep apnea
- Morbid obesity (e.g. BMI > 40kg/m2)> 40 kg/m2

General medical necessity and documentation

Conditions for coverage and documentation requirements

ALL of the following

Monitored anesthesia care is covered for elective upper and lower endoscopy for members with a higher risk for sedation-related complications
Member's medical records must document that services are medically necessary for the care provided
BCBSRI may audit services; all documentation must be available upon request and failure to produce requested information may result in denial or retraction of payment

Covered Codes

Covered CPT anesthesia codes for GI endoscopic proceduresCPTCovered

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 cholangiopancreatography (ERCP)
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

Provider Actions & Requirements

Documentation Required

Document medical necessity

Provider must document in the member's medical records that monitored anesthesia care (MAC) is medically necessary for the care provided. All documentation must be available to BCBSRI upon request for audit.

Medical records must document medical necessity.
Documentation must be available to BCBSRI upon request for audit.

Denial Risk

Payment denial or retraction risk if documentation not produced

Failure to produce requested documentation for BCBSRI audit may result in denial or retraction of payment.

Prior Authorization

Prior authorization not required

Prior authorization is not required for monitored anesthesia care (MAC) for gastrointestinal endoscopic procedures for Medicare Advantage Plans and Commercial Products.

Background and Evidence

Background: Monitored Anesthesia Care (MAC) involves drug-induced depression of consciousness during which patients may respond purposefully to verbal commands and requires monitoring by a practitioner qualified to administer anesthesia. MAC typically maintains cardiovascular function with spontaneous ventilation and includes pre-, intra-, and post-procedure anesthesia management; the provider must be prepared and qualified to convert to general anesthesia if needed.

Policy stance: The routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not considered appropriate. Indications for MAC depend on the nature of the procedure, the patient’s clinical condition, and potential need to convert to a general or regional anesthetic.

Guideline support: Recommendations in GI endoscopy sedation guidance (ASA and GI societies) note that routine MAC for average-risk patients is inappropriate and provide clinical situations to consider when screening patients to determine the appropriate level of sedation. The policy references ASA position statements and Gastrointest Endosc (2018) guidance consistent with ASA positions.

Evidence: Guideline citations include ASA position statements on Monitored Anesthesia Care and related ASA guidance, and GI endoscopy sedation guidelines (e.g., Gastrointest Endosc 2018). Multiple references are listed in the policy supporting these recommendations.

Definitions

Definitions: Monitored Anesthesia Care (MAC): Anesthesia care involves a drug-induced depression of consciousness during which the patient may respond purposefully to verbal commands and requires monitoring by a practitioner qualified to administer anesthesia; provider must be prepared and qualified to convert to general anesthesia when necessary. ASA Physical Status Classification: ASA I–VI scale describing patient preoperative physical health; ASA III–V indicate severe systemic disease.