CurrentModa HealthPolicy HCS-0004

Anesthesia for Routine Gastrointestinal Endoscopic Procedures

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Defines Moda Health coverage criteria for anesthesia (including monitored anesthesia care and deep sedation) for routine upper and lower GI endoscopic procedures and specifies when anesthesia services are covered for members.

Policy Summary

PayerModa Health

PolicyAnesthesia for Routine Gastrointestinal Endoscopic Procedures

Policy CodePolicy HCS-0004

Change TypeNo material change

Effective DateSep 1, 2025

Last ReviewAug 27, 2025

Next Review DateAug 27, 2025

Key ActionSubmit prior authorization with required documentation for anesthesia codes listed, except for Medicare members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASA I-II excludedAverage risk exclusion

BMI ≥40BMI threshold

<18 or >70Age indications

00731Referenced CPT

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CurrentModa HealthPolicy HCS-0004

Anesthesia for Routine Gastrointestinal Endoscopic Procedures

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Policy Summary

PayerModa Health

PolicyAnesthesia for Routine Gastrointestinal Endoscopic Procedures

Policy CodePolicy HCS-0004

Change TypeNo material change

Effective DateSep 1, 2025

Last ReviewAug 27, 2025

Next Review DateAug 27, 2025

Key ActionSubmit prior authorization with required documentation for anesthesia codes listed, except for Medicare members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASA I-II excludedAverage risk exclusion

BMI ≥40BMI threshold

<18 or >70Age indications

00731Referenced CPT

History, H&P, pre-anesthesia eval

Noridian LCDMedicare guidance

Coverage Criteria — When Anesthesia for Routine GI Endoscopy is Covered

Covered when ANY of the following indications are present

Moda Health will cover anesthesia services for routine upper and lower endoscopic procedures when one or more of the following indications are met:

Indications list: a. Patient with previous problems with anesthesia or sedation; b. Patient with prescribed or illicit benzodiazepine use; c. History of alcohol or drug abuse, or patients with increased tolerance to sedation and analgesic agents (e.g., chronic pain patients treated with opioids; occasional marijuana use does not by itself require MAC anesthesia); d. Patient undergoing prolonged or complex procedures; e. Morbidly obese patients with BMI >= 40 kg/m2; f. Patients with documented severe sleep apnea; g. Increased risk for complication due to severe comorbidity (ASA Class III physical status or greater); h. Patients younger than 18 years and older than 70 years of age; i. Patients with other documented co-morbid conditions that would prevent safe sedation without anesthesia services (e.g., neurologic conditions such as Parkinson's, cardiac conditions, uncooperative or combative patients, pregnancy); j. Increased risk of airway obstruction due to anatomic variant including any one of the following: i. History of stridor; ii. Dysmorphic facial features (e.g., Pierre-Robin syndrome or trisomy 21); iii. Jaw abnormalities including but not limited to micrognathia, trismus, retrognathia, or significant malocclusion; iv. Neck abnormalities (e.g., neck mass); v. Oral abnormalities (e.g., macroglossia).

Any single indication in this list is sufficient for coverage per policy.

Not covered for average-risk patients

Coverage exclusion for average-risk patients

Exclusion: Moda Health will NOT cover anesthesia services to provide deep sedation and analgesia for routine upper and lower endoscopic procedures for average risk patients (ASA Class I and Class II).

Medicare members are exempt from prior authorization per section A of the policy.

Billing and Medicare compliance — Use listed diagnosis codes when billing CPT 00731 and follow Medicare/NCD/LCD guidance

Use one of the listed diagnosis codes when billing CPT 00731 and follow Medicare/NCD/LCD guidance where applicable.

Billing requirements: Anesthesia billed with CPT 00731 should be supported by an applicable ICD-10 diagnosis from Appendix 2 (examples: R16.0, R16.1, R18, R19.8) AND must comply with Medicare Benefit Policy Manual and any relevant National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs), including any applicable LCDs such as Noridian L35049 for Monitored Anesthesia Care when billing Medicare Part B.

Additional indications may be covered at the health plan's discretion; providers should consult the CMS coverage database and applicable MAC/LCD guidance.

This policy does not apply to Medicare members for the purposes of prior authorization. Prior authorization is NOT required for Medicare members, and requests for prior authorization under this policy should not be submitted for Medicare Part B beneficiaries. (See Medicare-specific guidance in Appendix 2 for billing and coverage requirements.)

In addition to the indications listed in this policy, additional indications may be covered at the health plan's discretion. Providers should be aware that Medicare Part B billing and coverage must follow the Medicare Benefit Policy Manual and any applicable NCDs/LCDs; when Medicare rules apply, plan discretion does not override Medicare determinations.

Deep sedation or anesthesia solely to provide deep sedation and analgesia for routine upper and lower endoscopic procedures in average-risk patients is not covered. Specifically, Moda Health will NOT cover anesthesia services for deep sedation/analgesia for patients who are ASA Class I or ASA Class II when the only indication is routine endoscopy.

Within the cited source material there are no additional explicit statements labeled 'not medically necessary' beyond the policy exclusion for average-risk (ASA I–II) patients; the document instead references Medicare coverage rules and notes that the plan may consider additional indications at its discretion.

Coding — Applicable Procedure, Modifier, and Diagnosis Codes

Applicable Anesthesia CPT CodesCPTCovered

00731	Anesthesia for upper endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified.
00740	Anesthesia, Upper GI endoscopy procedure, proximal duodenum.
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 endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum.

Anesthesia Modifiers / ASA classificationsModifier

P1	A normal healthy patient (ASA Class I).
P2	A patient with mild systemic disease (ASA Class II).
P3	A patient with severe systemic disease (ASA Class III).
P4	A patient with severe systemic disease that is a constant threat to life (ASA Class IV).
P5	A moribund patient who is not expected to survive without the operation (ASA Class V).

Applicable diagnosis codes (select examples across appendices 1-2)ICD-10

C18.9	Malignant neoplasm of colon, unspecified.
C19	Malignant neoplasm of rectosigmoid junction.
E66.01	Morbid (severe) obesity from excess calories.
E66.2	Morbid (severe) obesity with alveolar hypoventilation.
F10.20	Alcohol dependence, uncomplicated.
F19.20	Other psychoactive substance dependence, uncomplicated.
G47.33	Obstructive Sleep Apnea.
K50	Crohn disease [regional enteritis].
K92.2	Gastrointestinal hemorrhage, unspecified.
R10.0	Acute abdominal pain, severe, localized, rapid onset.

Applicable Diagnosis Codes for CPT 00731ICD-10Covered

R16	Splenomegaly, not elsewhere classified
R16.0	Hepatomegaly, not elsewhere classified
R16.1	Splenomegaly, not elsewhere classified
R18	Ascites
R19.8	Other specified symptoms and signs involving the digestive system and abdomen

Referenced Procedure CodeCPT

00731

Anesthesia for procedures on upper gastrointestinal tract (listed as referenced CPT)

Body mass index (BMI) threshold used as indication

BMI thresholdMorbid obesity defined as BMI ≥ 40 kg/m2

Context of useListed as an indication that alone qualifies for coverage of anesthesia services for routine endoscopic procedures

Policy locationIncluded in coverage indications (Section II.C.e)

Provider Actions — Prior Authorization, Documentation, and Billing Steps

Prior Authorization

Prior authorization required for anesthesia codes (non‑Medicare)

Prior authorization is required for anesthesia services billed with CPT codes 00731, 00740, 00811, 00812, and 00813 for routine gastrointestinal endoscopic procedures for non‑Medicare members; submit the required documentation when requesting coverage for these anesthesia codes.

Prior authorization applies to anesthesia codes: 00731, 00740, 00811, 00812, 00813
Medicare members are exempt from the prior authorization requirement

Note

Follow Medicare Benefit Policy and applicable NCDs/LCDs for Medicare Part B

When billing Medicare Part B, follow the Medicare Benefit Policy Manual and any applicable National or Local Coverage Determinations (NCDs/LCDs) such as Noridian LCDs; compliance with these Medicare policies is required where applicable.

Medicare Benefit Policy Manual and CMS coverage database guidance apply

Definitions — Sedation Levels and Monitored Anesthesia Care

Monitored anesthesia care (MAC) definition summary

Definition (summary)Monitored anesthesia care (MAC) denotes anesthesia services administered by anesthesia personnel who provide a pre-anesthesia evaluation, are present for the entire procedure, and are prepared to convert to general anesthesia and manage the airway if needed.

Relation to sedation levelMAC is not necessarily related to the level of anesthesia administered; it refers to the involvement of anesthesia personnel rather than a specific depth of sedation.

Deep sedation noteDeep sedation with propofol must be administered by anesthesia personnel and is considered MAC when anesthesia personnel provide the described services.

Levels of sedation — minimal, moderate, deep, general anesthesia (ASA definitions)

Minimal sedationA drug-induced state in which patients respond normally to verbal commands; airway, ventilation, and cardiovascular function remain unaffected.

Background

Gastrointestinal endoscopic procedures are commonly performed with intravenous sedation across a range of depths from minimal sedation to general anesthesia. For routine upper and lower endoscopy, moderate sedation (conscious sedation) is typically sufficient and is often administered by nursing staff or a physician assistant under the endoscopist's direction. Monitored anesthesia care (MAC) involves anesthesia personnel providing a pre-anesthesia evaluation, being present for the entire procedure, and being prepared to convert to general anesthesia and manage the airway; deep sedation with agents such as propofol must be administered by anesthesia personnel.

Revision History

2025-09-01Effective dateLatest

Policy effective date updated to 2025-09-01 following annual review (08/27/2025).

08/27/2025Annual review

Annual review completed with no content changes noted in the document (review date 08/27/2025).

08/01/2024Annual review

Policy Summary

PayerModa Health

PolicyAnesthesia for Routine Gastrointestinal Endoscopic Procedures

Policy CodePolicy HCS-0004

Change TypeNo material change

Effective DateSep 1, 2025

Last ReviewAug 27, 2025

Next Review DateAug 27, 2025

Key ActionSubmit prior authorization with required documentation for anesthesia codes listed, except for Medicare members.

SourceLink

On This Page

Noridian LCD L35049 (Monitored Anesthesia Care) is referenced for Medicare Part B

Documentation Required

Confirm Medicare status on authorization requests

Ensure prior authorization requests clearly state whether the member is Medicare; this policy does not require prior authorization for Medicare members and Medicare coverage is governed by NCDs/LCDs.

Policy statement: prior authorization is NOT required for Medicare members
Medicare coverage must follow NCDs/LCDs as applicable

Denial Risk

Comply with LCD/NCD requirements for Medicare billing

If billing Medicare Part B, document and follow any applicable contractor LCD/NCD requirements (e.g., Noridian MAC LCD) because Medicare coverage and prior authorization requirements differ from the plan’s non‑Medicare rules.

Noncompliance with applicable NCDs/LCDs can affect Medicare Part B coverage determinations
Additional indications may be covered at the health plan’s discretion, but Medicare determinations follow CMS guidance

Documentation Required

Documentation to submit with prior authorization

Include the following documents with the prior authorization request when available: pre‑procedure history and physical, pre‑anesthesia evaluation, provider notes documenting co‑morbid conditions, and sleep study documenting significant obstructive sleep apnea if applicable.

Pre‑procedure history and physical
Pre‑anesthesia evaluation
Provider notes documenting co‑morbid medical conditions
Sleep study documenting significant OSA (if OSA is the indication)

Billing Rule

Use an applicable diagnosis code when billing CPT 00731

When billing anesthesia CPT 00731, support the claim with an applicable ICD‑10 diagnosis from Appendix 2 (examples include R16.0, R16.1, R18, R19.8) to justify the procedure.

Examples of applicable diagnosis codes for CPT 00731: R16.0, R16.1, R18, R19.8
CPT 00731 = Anesthesia for upper endoscopic procedures (endoscope introduced proximal to duodenum)

Denial Risk

Denial risk for ASA I–II (average‑risk) patients

There is a high risk of denial if anesthesia is provided for routine upper or lower endoscopic procedures for average‑risk patients (ASA Class I and II), as Moda Health will NOT cover deep sedation/anesthesia for these patients.

Policy: NOT covered for deep sedation/anesthesia for average‑risk patients (ASA Class I and II)
Ensure documentation demonstrates one or more covered indications before billing to avoid denial

Denial Risk

Medicare/LCD noncompliance may affect Part B coverage

Failure to follow applicable NCDs/LCDs (for example Noridian LCD L35049 for Monitored Anesthesia Care) when billing Medicare Part B may lead to adverse Medicare coverage determinations.

Medicare Part B coverage is governed by CMS manuals and NCDs/LCDs
Noridian LCD L35049 is a referenced local coverage determination for MAC

Moderate sedation (conscious sedation)A drug-induced depressed level of consciousness in which patients can purposefully respond to verbal command or tactile stimulation; no airway intervention required; ventilation adequate and cardiovascular function usually maintained.

Deep sedationA drug-induced depressed level of consciousness in which patients cannot be easily aroused but respond purposefully after repeated or painful stimuli; airway intervention may be required; spontaneous ventilation may be inadequate.

General anesthesiaA drug-induced loss of consciousness in which patients are not arousable, even by painful stimuli; patients require airway assistance and may need positive pressure ventilation; cardiovascular function may be impaired.

Examples of diagnosis codes referenced for CPT 00731

Examples (Appendix 2)R16.0 — Hepatomegaly, not elsewhere classified

Examples (Appendix 2)R16.1 — Splenomegaly, not elsewhere classified

Examples (Appendix 2)R18 — Ascites

Examples (Appendix 2)R19.8 — Other specified symptoms and signs involving the digestive system and abdomen

Grammar updates to the history of drug or alcohol abuse wording implemented with an effective date of 09/01/2024.

10/01/2023Annual review with content addition

Added coverage requirement for increased risk of airway obstruction and added ICD‑10 codes in the appendix (annual review 09/2023; effective 10/01/2023).

09/01/2022Annual review

Annual review completed with no changes (08/2022 review; effective 09/01/2022).

10/01/2021Update

Clarified wording regarding occasional marijuana use (update recorded 10/2021).

01/01/2018Code update

Updated with new anesthesia codes for 2018 (12/06/2017 update; effective 01/01/2018).

08/22/2018Annual review

Annual review noting Medicare does not apply to prior authorization (08/2018; effective 08/22/2018).