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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity Health Alliance HSA anesthesia coverage…
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    CurrentUniversity Health Alliance (HSA)Policy MPP-0033-120301

    Anesthesia Services for Gastrointestinal Endoscopic Procedures

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    Defines medical necessity criteria, limitations, and administrative rules for reimbursement of monitored anesthesia care, regional or general anesthesia for gastrointestinal endoscopic procedures for University Health Alliance members and contracted providers.

    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyAnesthesia Services for Gastrointestinal Endoscopic Procedures
    Policy CodePolicy MPP-0033-120301
    Change TypeNo material changes
    Effective DateJun 2, 2021
    Last ReviewJun 2, 2021
    Next Review Date
    Key ActionPrior authorization is not required; obtain a signed Member Agreement of Financial Responsibility ≥24 hours before the procedure if criteria are not met and the member requests anesthesia.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Multiple
    criteria categories
    Not requiredprior auth
    Agreement requiredfinancial process
    Average-risk adultsexclusion

    Medical Necessity Criteria

    Medical necessity criteria for anesthesia

    Monitored anesthesia care (MAC), regional anesthesia, or general anesthesia are covered when ONE or more of the following indications are present.

    Any of the following high‑risk patient conditions (ASA P3 or P4)

    • ASA P3 or P4 patient with increased risk for complications due to one or more of the following conditions:

    • ANY of the following

      • Morbid obesity: BMI >= 40
      • Morbid obesity: BMI >= 35 with significant comorbid conditions (e.g., coronary artery disease, diabetes mellitus, hypertension, abnormal airway findings)
      • Clinically significant cardiac disease (e.g., coronary artery disease, valvular heart disease, congestive heart failure, arrhythmia) or poorly controlled hypertension; or history of myocardial infarction, angioplasty, coronary stents, CABG, pacemaker, automatic implanted cardioverter defibrillator
      • Kidney disease: end stage renal disease or chronic kidney disease requiring routine nephrology care
      • Significant neurologic disorder: history of stroke/TIA requiring hospitalization or neurologist evaluation; severe neuromuscular disorder (e.g., Parkinson's, ALS, MS, muscular dystrophy); spasticity/movement disorder complicating the procedure; inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
      • Significant respiratory disease: clinically significant respiratory disease requiring chronic daily medication and/or oxygen (e.g., COPD, moderate persistent asthma, interstitial lung disease, pulmonary hypertension)
      • Documented obstructive sleep apnea (OSA) requiring positive airway pressure or oral device; suspected OSA without sleep study for urgent procedures in patients with BMI >= 30 with documentation of high risk of OSA
      • Chronic severe psychiatric disorder that impedes safe cooperation (e.g., schizophrenia, bipolar disorder, major depressive disorder)
      • Increased aspiration risk (foreign body, retained food, gastroparesis, achalasia, ascites)
      • Type 1 diabetes or poorly controlled type 2 diabetes and/or diabetes with complications
      • Severe liver disease, including cirrhosis

    Prolonged or therapeutic endoscopic procedures

    • Endoscopic procedures that are prolonged or therapeutic and require deep sedation, e.g., ERCP, balloon enteroscopy, foreign body extraction from upper GI tract, percutaneous endoscopic gastrojejunostomy/direct percutaneous jejunostomy, esophageal stenting, endoscopic mucosal resection of the upper GI tract, esophageal ablation, endoscopic ultrasound of the upper GI tract, and colonic stenting

    • Combination of upper endoscopy and colonoscopy is not considered a prolonged procedure requiring anesthesia

    Problems with sedation

    • Difficulty or anticipated difficulty with sedation due to one or more of the following: chronic opioid treatment; chronic benzodiazepine treatment beyond occasional/nightly use; chronic and significant substance abuse/dependence documented in medical record (including alcohol >16 drinks/week for men or >10 drinks/week for women); chronic daily marijuana use; uncooperative or agitated patients (e.g., dementia, organic brain disease); documented history of being difficult to sedate during a prior procedure
    • Allergy to fentanyl and/or midazolam documented in the medical record or prior anesthesia record (allergy to other narcotics or benzodiazepines is not considered a high‑risk indication)
    • History of severe problems with anesthesia or sedation (e.g., malignant hyperthermia, difficult intubation, difficult mask ventilation) documented in the medical record or prior anesthesia record/post‑op report

    Airway risk

    • Increased risk of airway obstruction as determined prior to the day of the procedure by a qualified specialist in a patient who: is expected to require more than moderate procedural sedation; and is at increased risk for sedation due to obesity (BMI >= 35) or another listed medical condition; or will be having a prolonged procedure (not including combined upper endoscopy and colonoscopy)
    • Documented history of tracheal stenosis or prior tracheostomy or radiation to the neck

    Age and pregnancy

    • Patient < 18 years of age
    • Patient >= 70 years of age
    • Pregnancy

    Anesthesia CPT Codes for GI Endoscopic Procedures

    Anesthesia CPT codes for GI endoscopic proceduresCPT
    00731Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
    00732Anesthesia for upper gastrointestinal endoscopic procedures; endoscopic retrograde cholangiopancreatography (ERCP)
    00811Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
    00812Anesthesia for lower intestinal endoscopic procedures; screening colonoscopy
    00813Anesthesia for combined upper and lower gastrointestinal endoscopic procedures

    Prior Authorization, Review, and Financial Responsibility

    Prior Authorization

    Prior authorization not required; UHA may perform retrospective review

    Prior authorization is not required for anesthesia services for gastrointestinal endoscopic procedures. UHA reserves the right to perform retrospective review using the policy criteria to validate that services rendered met payment determination. If the policy criteria are not met and the member requests anesthesia, the Member Agreement of Financial Responsibility must be completed and signed (see next action).

    Billing Rule

    Obtain signed Member Agreement of Financial Responsibility ≥24 hours before procedure

    If there is a reasonable expectation that the policy criteria will not be met and the member still requests anesthesia, the Member Agreement of Financial Responsibility must be signed at least 24 hours prior to the procedure; completion on the day of service is invalid and the patient will not be held financially responsible.

    Scope and Definitions

    ASA classification — ASA P1–P6 definitions
    P1A normal healthy patient
    P2A patient with mild systemic disease
    P3A patient with severe systemic disease
    P4A patient with severe systemic disease that is a constant threat to life
    P5A moribund patient who is not expected to survive without the operation
    P6A declared brain-dead patient whose organs are being removed for donor purposes
    Policy scope note — payment policy guidance
    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyAnesthesia Services for Gastrointestinal Endoscopic Procedures
    Policy CodePolicy MPP-0033-120301
    Change TypeNo material changes
    Effective DateJun 2, 2021
    Last ReviewJun 2, 2021
    Next Review Date
    Key ActionPrior authorization is not required; obtain a signed Member Agreement of Financial Responsibility ≥24 hours before the procedure if criteria are not met and the member requests anesthesia.
    SourceLink
    On This Page
    Medical Necessity CriteriaAnesthesia CPT Codes for GI Endoscopic ProceduresPrior Authorization, Review, and Financial ResponsibilityScope and Definitions
    • Member must be informed of the financial implications.
    • The Agreement must be kept on file by the endoscopist and anesthesia provider.
    • If completed on the day of service it is not valid and UHA will not hold the patient financially responsible.
    • UHA will process the claim to indicate member responsibility for payment for this separate anesthesia service.
    Policy purposeThis UHA payment policy is a guide to coverage and administrative directives, not a guarantee of payment
    Not medical practice instructionThe policy is not meant to provide instruction in the practice of medicine and should not deter a provider from expressing clinical judgment
    Contract and benefit plan variabilitySpecific provider contract terms and individual member benefit plans may affect payment
    ApplicabilityUHA reserves the right to apply this payment policy to all UHA companies and subsidiaries
    Reconsideration of medical necessityProviders may request that UHA reconsider application of medical necessity criteria with supporting documentation