CurrentIndependent HealthPolicy M20190321021

Monitored Anesthesia Care for Gastrointestinal Procedures

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

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.

15Listed clinical indications

NoPre-authorization required

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.

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
Airway obstruction risk: Increased risk of airway obstruction due to anatomic variation (e.g., abnormalities of the oral cavity, neck or jaw, dysmorphic facial features)
Inability to follow commands: Inability to follow simple commands due to cognitive dysfunction or psychological impairment
Spasticity or movement disorder complicating procedure
History of sedative intolerance: History or anticipated intolerance to standard sedatives due to chronic opioid or benzodiazepine use
Active substance-related problems: Active medical problems related to drug or alcohol abuse
Older age: Age older than 70age > 70 years
Younger age: Age younger than 18 yearsage < 18 years
Pregnancy
Previous anesthesia problems: Documented history of previous problems with anesthesia or sedatives (e.g., failure of moderate sedation)
Prolonged or therapeutic procedure requiring deep sedation
Acutely agitated or uncooperative patients (e.g., delirium, organic brain disease, dementia)

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.

Periodic retrospective audits and post-service, pre-pay reviews will be performed to ensure compliance.
Claims not meeting the documented clinical criteria are subject to denial on retrospective review.

Prior Authorization

Pre-authorization not required

Pre-authorization is not required at the present time. The clinical criteria in this policy will be used for retrospective review of MAC claims.

No pre-authorization required currently across applicable lines of business.
Claims will be reviewed retrospectively against the listed medical necessity indications (e.g., ASA class 3+, BMI >40, age >70 or <18, pregnancy, etc.).

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

Policy reviewed on 4/1/2025 (Notes: Reviewed).

2024-04-01revision

4/1/2024 revised (record indicates revision).

2023-11-01revision

11/1/2023 revised (record indicates revision).

2023-04-01policy_review

Policy reviewed on 4/1/2023 (Notes: Reviewed).

2022-04-01policy_review

Policy reviewed on 4/1/2022 (Notes: Reviewed).

2021-04-01policy_review

Policy reviewed on 4/1/2021 (Notes: Reviewed).

2020-04-01revision

4/1/2020 revised (record indicates revision).

2019-08-01effective_date

Policy effective date 8/1/2019 (Effective Date changed from 5/1/2019).