CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures

Policy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures (upper and lower endoscopy) for BlueCHiP for Medicare and Commercial products, including criteria for when MAC is appropriate and CPT codes covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review DateN/A

Key ActionDocument medical necessity for MAC in the member's medical records; BCBSRI may audit and deny or retract payment if requested documentation is not produced.

SourceLink

POLICY UPDATE CHANGES

No material changes — the policy has no material clinical or coverage changes.

5Key covered CPT codes listed

15Coverage circumstances/indications listed

Coverage Summary

scope_summary: This policy governs coverage of Monitored Anesthesia Care (MAC) for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures (upper and lower endoscopy) for BlueCHiP for Medicare and Commercial products, including criteria for when MAC is appropriate and the CPT codes covered.

overview: MAC is covered for elective upper and lower endoscopy for members at increased risk for sedation-related complications (for example, pediatric or elderly patients, pregnancy, anatomic airway risks, significant comorbidity corresponding to ASA P2 or greater, morbid obesity such as BMI > 40, obstructive sleep apnea, history of inadequate response or adverse reaction to sedation, active substance use disorder, and similar indications). Documentation of medical necessity must be available to BCBSRI on request.

Key Quick Facts

Effective date07/01/2018

Last review11/19/2019

StatusCURRENT

Scope summaryPolicy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures (upper and lower endoscopy) for BlueCHiP for Medicare and Commercial products, including criteria for when MAC is appropriate and CPT codes covered.

BMI thresholdBMI > 40

ASA thresholdP2 or greater

When MAC Is Medically Necessary

Coverage Criteria for MAC for GI Endoscopy

Monitored anesthesia care for gastrointestinal endoscopic procedures is a covered service for elective upper and lower endoscopy for members with a higher risk for sedation-related complications when medical records document medical necessity. MAC is considered appropriate in the following circumstances:

Age: Member is under 18 years of age
Age: Member is over 70 years of age
Pregnancy: Member is pregnant
Airway anatomic risk: Increased risk for airway obstruction due to anatomic variation
examples: macroglossia, dysmorphic facial features, neck mass, micrognathia
ASA physical status: Increased risk for complications due to severe co-morbidity corresponding to ASA Physical Status Modifier of P2 or greaterP2 or greater
ASA Physical Status modifiers per policy
Stridor history: History of stridor
Oral abnormalities (e.g., macroglossia)
Facial features: Dysmorphic facial features
Neck abnormalities (e.g., neck mass)
Jaw abnormalities (e.g., micrognathia)
Adverse reaction: History of adverse reaction to sedation
Inadequate response: History of inadequate response to sedation
Morbid obesity (e.g., BMI > 40)BMI > 40
OSA: Obstructive sleep apnea
Substance use: Active alcohol or substance use disorder

CPT Codes

Covered CPT codes for MAC in GI endoscopyCPTCovered

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 Requirements

Prior Authorization

Prior authorization not required

Prior authorization is not required for monitored anesthesia care for gastrointestinal endoscopic procedures for BlueCHiP for Medicare and Commercial Products.

Documentation Required

Medical necessity documentation required

Member medical records must document that monitored anesthesia care services are medically necessary for the care provided. Blue Cross Blue Shield of Rhode Island (BCBSRI) maintains the right to audit the services provided and may request all documentation; failure to produce requested information may result in denial or retraction of payment.

Denial Risk

Denial risk for insufficient documentation

Claims may be denied or payment retracted if requested documentation demonstrating medical necessity is not produced upon BCBSRI request.

Background & Evidence

Monitored Anesthesia Care (MAC) involves drug-induced depression of consciousness in which the patient may respond purposefully to verbal commands, with monitoring by a practitioner qualified to administer anesthesia and prepared to convert to general anesthesia if necessary. Typically cardiovascular function is maintained and spontaneous ventilation is usually adequate. The intent of this policy is to address MAC services for gastrointestinal endoscopic diagnostic or therapeutic procedures performed in the outpatient setting.

MAC is intended for use based on the nature of the procedure, the patient’s clinical condition, and/or the potential need to convert to general or regional anesthesia; indications include support of vital functions, diagnosis and treatment of intra-procedure clinical problems, administration of sedatives/analgesics/anesthetic agents as necessary for patient safety, and provision of other medical services required to complete the procedure safely.

The American Society for Gastrointestinal Endoscopy (ASGE) guideline (2008) states that the routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate. ASGE recommendations advise clinicians to screen patients to determine the appropriate level of sedation or need for MAC.

Evidence and guideline sources cited in this policy include the American Society for Gastrointestinal Endoscopy (ASGE) 2008 guideline on sedation and anesthesia in GI endoscopy and American Society of Anesthesiologists (ASA) position statements: "Position on Monitored Anesthesia Care" (2013) and ASA statements on anesthesia care for endoscopic procedures and related topics (2014).

The ASA position describes MAC as a specific anesthesia service that includes pre-procedure assessment, intra-procedure management, and post-procedure anesthesia care; indications depend on procedure complexity, patient condition, and potential need to convert to a general or regional anesthetic. The ASA emphasizes that MAC providers must be prepared and qualified to convert to general anesthesia when necessary.

Definitions

Clinical terms