CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

Policy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures (upper and lower GI endoscopy) for Medicare Advantage and commercial products, including clinical indications, CPT codes covered, documentation and audit rights, and prior authorization rules.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review DateN/A

Key ActionMember's medical records must document that MAC services are medically necessary for the care provided; BCBSRI may audit and require production of documentation and may deny or retract payment if documentation is not produced.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

5+Key clinical indication categories listed

5Covered CPT codes

2022-12-21Policy last updated (publication date shown)

Coverage Summary

Policy governs coverage of Monitored Anesthesia Care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures (upper and lower GI endoscopy) for Medicare Advantage and commercial products. The policy aligns with guidance from the American Society of Anesthesiologists (ASA) and the American Society for Gastrointestinal Endoscopy (ASGE), and states that routine MAC for average-risk patients undergoing standard endoscopy is not appropriate. Effective date: 07/01/2018; policy last updated/published: 12/21/2022.

Medical-Necessity Criteria

Coverage Criteria for MAC for GI Endoscopic Procedures

MAC is considered appropriate for outpatient upper or lower GI endoscopy when ANY of the following patient, procedure, or risk conditions are present:

ANY of the following

Member is under 18 years of age
Member is over 70 years of age
Member is pregnant
Increased risk for complications due to severe co-morbidity corresponding to the American Society of Anesthesiologists (ASA) Physical Status Modifier of P2 or greater
Member is acutely agitated and/or uncooperative
Increased risk for airway obstruction due to anatomic variation
- Dysmorphic facial features
- History of stridor
- Oral abnormalities (e.g., macroglossia)
- Jaw abnormalities (e.g., micrognathia)
- Neck abnormalities (e.g., neck mass)
Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Endoscopy in members with adhesions after abdominal surgery
- Stent placement in the upper gastrointestinal tract
Complex therapeutic procedures or history-related indications
- Complex therapeutic procedures, such as plication of the cardioesophageal junction
- History of adverse reaction to sedation
- History or anticipated intolerance to standard sedatives
- History of inadequate response to sedation
- Chronic opioid use
- Documented apnea; sleep (sleep apnea implied)

General MAC Definition / Provider Qualification

Coverage applies when MAC is provided by a practitioner qualified to administer anesthesia and prepared to convert to general anesthesia if needed:

ALL of the following

Provider is qualified to administer anesthesia and monitor patient; prepared and qualified to convert to general anesthesia if patient loses ability to respond purposefully
MAC includes pre-procedure visit, intra-procedure care and post-procedure anesthesia management
Services must be medically necessary and documented in member medical records

Coding

Covered CPT codes for MAC 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

Documentation Required

Medical necessity documentation required

Member medical records must document that MAC services are medically necessary for the care provided. BCBSRI may audit services and require production of documentation; failure to produce requested information can affect payment.

Failure to produce requested documentation may result in denial or retraction of payment
Maintain complete medical records demonstrating medical necessity for MAC

Prior Authorization

Prior authorization not required

For Medicare Advantage Plans and Commercial Products, prior authorization is not required for monitored anesthesia care for gastrointestinal endoscopic procedures.

Billing Rule

Benefits may vary by contract

Benefits for anesthesia and surgery services may vary by group or contract; providers should refer to the member's applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine coverage and benefits.

Denial Risk

Audit and payment retraction risk

BCBSRI reserves the right to audit services and may deny or retract payment if requested documentation is not provided upon request.

BCBSRI may audit services regardless of provider participation status
Requested documentation must be made available to BCBSRI

Background, Evidence & Definitions

Monitored Anesthesia Care (MAC) is defined as anesthesia care involving a drug-induced depression of consciousness in which the patient may respond purposefully to verbal commands and is monitored by a practitioner qualified to administer anesthesia; the provider must be prepared and qualified to convert to general anesthesia if needed. The policy aligns with ASA and ASGE guidance that the routine use of MAC for average-risk patients undergoing standard upper or lower GI endoscopy is not appropriate and instead defines specific patient, procedure, and risk-based situations in which MAC is considered appropriate for safety and procedural complexity.

Evidence summary: Guideline references — ASA and ASGE guidelines and multiple peer‑reviewed studies are cited to support the policy (see policy references).

Definitions

Monitored Anesthesia Care (MAC): Anesthesia care involving drug-induced depression of consciousness with patient possibly responsive to verbal commands; provider must monitor and be qualified to convert to general anesthesia if needed.

ASA Physical Status Modifiers: P1: normal healthy patient; P2: mild systemic disease; P3: severe systemic disease; P4: severe systemic disease that is a constant threat to life; P5: moribund patient not expected to survive without the operation; P6: declared brain-dead organ donor.