CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for GI endoscopic procedures

Policy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures for Medicare Advantage and commercial products, specifying clinical indications, required documentation, and applicable CPT and modifier reporting.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) for GI endoscopic procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review DateN/A

Key ActionDocument in the member's medical record that MAC is medically necessary for the care provided; records must be available for BCBSRI audit and failure to produce them may result in denial or retraction of payment

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

5+Key clinical indication categories listed

5Covered CPT codes

Coverage Summary — Monitored Anesthesia Care (MAC) for GI Endoscopic Procedures

Scope: Policy governs coverage of monitored anesthesia care (MAC) for outpatient upper and lower gastrointestinal endoscopic diagnostic and therapeutic procedures for Medicare Advantage and commercial products. Coverage stance: Covered with criteria. Status: CURRENT. Effective date: 07/01/2018. Last review date: 01/08/2025.

Overview: Monitored Anesthesia Care (MAC) is covered for elective upper and lower GI endoscopic procedures when the documented clinical indications specified by the policy are met. The policy lists patient age extremes, pregnancy, uncooperative behavior, ASA class III–V, airway anatomic risks, prolonged or complex therapeutic procedures, and conditions associated with sedation intolerance as indications for MAC, and specifies required documentation, facility and provider requirements, and applicable CPT and ASA physical status modifiers for billing.

Policy at a glance

PolicyView PDF payer: Medicare Advantage Plans and Commercial Products

ScopePolicy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures for Medicare Advantage and commercial products, specifying clinical indications, required documentation, and applicable CPT and modifier reporting.

Coverage stancecovered_with_criteria

StatusCURRENT

Effective date2018-07-01

Last review2025-01-08

Next review