CurrentIndependent HealthPolicy M20190321021

Monitored Anesthesia Care for Gastrointestinal Procedures

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Defines Independent Health's medical necessity criteria for use of monitored anesthesia care (MAC) during gastrointestinal endoscopic procedures (e.g., colonoscopy, endoscopy) across Commercial, Self-Funded, MediSource, MediSource Connect, Child Health Plus, Essential Plan, and Medicare Advantage lines of business. Specifies documentation, audit, and denial conditions; pre-authorization is not required.

Policy Summary

PayerIndependent Health

PolicyMonitored Anesthesia Care for Gastrointestinal Procedures

Policy CodePolicy M20190321021

Change TypeReviewed / Formatting only

Effective DateAug 1, 2019

Last ReviewApr 1, 2026

Next Review Date

Key ActionEnsure anesthesiologist documentation clearly demonstrates one or more listed high-risk situations or MAC claims may be denied on retrospective review.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed on 4/1/2026 with notes = Reviewed.

8/1/2025 revised - Formatting only.

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CurrentIndependent HealthPolicy M20190321021

Monitored Anesthesia Care for Gastrointestinal Procedures

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Policy Summary

PayerIndependent Health

PolicyMonitored Anesthesia Care for Gastrointestinal Procedures

Policy CodePolicy M20190321021

Change TypeReviewed / Formatting only

Effective DateAug 1, 2019

Last ReviewApr 1, 2026

Next Review Date

Key ActionEnsure anesthesiologist documentation clearly demonstrates one or more listed high-risk situations or MAC claims may be denied on retrospective review.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed on 4/1/2026 with notes = Reviewed.

8/1/2025 revised - Formatting only.

Coverage Summary

Scope: Defines Independent Health's medical necessity criteria for Monitored Anesthesia Care (MAC) during gastrointestinal endoscopic procedures (e.g., colonoscopy, endoscopy) across Commercial, Self‑Funded, MediSource, MediSource Connect, Child Health Plus, Essential Plan, and Medicare Advantage lines of business. Policy Number: M20190321021. Subject: Monitored Anesthesia Care (MAC) for Gastrointestinal Procedures.

Coverage stance: Covered with criteria — MAC is considered medically necessary when documentation by the anesthesiologist clearly demonstrates one or more listed high‑risk situations. Effective date: 8/1/2019. Last review: 4/1/2026.

Thresholds and key stats

ASA physical status thresholdClass 3 or greater (severe systemic disease)

Body mass index threshold> 40 (morbid obesity)

Age upper threshold> 70 years

Age lower threshold< 18 years

Listed clinical indications count15

Pre-authorization requiredNo

Medically Necessary Indications for Monitored Anesthesia Care (MAC)

Medically Necessary Indications for MAC

Monitored anesthesia care may be considered medically necessary when documentation by the anesthesiologist clearly demonstrates ONE or more of the following:

Severe co-morbidity: Increased risk for complications due to severe co-morbidity (ASA class 3 physical status or greater)ASA class 3 or greater
see Definitions
Severe sleep apnea that requires use of a positive pressure airway device during sleep
Morbid obesity (Body mass index >40)BMI > 40

Coding

Anesthesia Policy Reference / Billing guidancemixed

No codes listed

Provider Actions & Authorization

Documentation Required

Anesthesiologist documentation required

Anesthesia claims will be denied if provided clinical documentation does not indicate compliance with the clinical criteria; documentation must clearly demonstrate one or more listed high-risk situations.

Documentation must clearly demonstrate one or more of the listed higher-risk situations (see Clinical Indications).
Anesthesiologist should document pre-procedure assessment, intraprocedural care and post-procedural management as part of MAC service description.

Denial Risk

Retrospective audit and denial risk

Independent Health will conduct periodic retrospective audits and post-service, pre-pay reviews. MAC claims may be denied on retrospective review if the documentation does not meet the policy's clinical criteria.

Background & Definitions

Background: Monitored Anesthesia Care (MAC) is an anesthesia service by a qualified anesthesia provider that includes pre‑procedure assessment, intra‑procedural monitoring and post‑procedural management, with the ability to provide deeper sedation than moderate sedation. National guidelines (e.g., ASA, ASGE, AGA) and peer‑reviewed literature support MAC for outpatients with certain risk factors or significant medical conditions. Typical procedural context: MAC is used for diagnostic or therapeutic gastrointestinal endoscopic procedures (such as colonoscopy and upper endoscopy) when deeper sedation or anesthesia clinician management is indicated.

Purpose: The policy sets forth Independent Health's criteria for use of MAC during GI procedures and specifies documentation requirements, periodic retrospective audits, and potential denial of anesthesia claims if clinical documentation does not demonstrate compliance with the criteria.

Term	Definition
Monitored Anesthesia Care (MAC)	An anesthesia service provided by a qualified anesthesia provider including pre-procedure assessment, intraprocedural care, postprocedural care, diagnosis and treatment of problems that occur, support of vital functions (including airway management), and administration of sedatives/analgesics as needed; allows for a maximal depth of sedation in excess of that provided during moderate sedation and may convert to general anesthesia if required.
Moderate sedation	A proceduralist-directed service that does not include a qualified anesthesia provider's periprocedural assessment; the responsible physician typically performs the procedure and supervises sedation and/or analgesic medications to allay anxiety and limit pain.
ASA physical status classification	I: normal healthy; II: mild systemic disease; III: severe systemic disease; IV: severe systemic disease that is a constant threat to life; V: moribund not expected to survive without operation; VI: brain-dead organ donor.

Evidence and guideline support: Cited societies and references include the American Society of Anesthesiologists (ASA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), and peer‑reviewed literature (for example, ASGE 2018 guidelines and a 2016 systematic review). These sources inform the criteria for when MAC is medically necessary during GI endoscopic procedures.

Revision History

2026-04-01policy_reviewLatest

Policy reviewed on 4/1/2026 (Notes: Reviewed).

2025-08-01formatting_revision

8/1/2025 revised - Formatting only (non-material).

2025-04-01policy_review