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Moderate (conscious) sedation is generally used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patient’s ability to respond to stimulation. It includes pre- and post-sedation evaluations, administration of sedation, and monitoring of the cardiorespiratory functions (heart rate, blood pressure, and oxygen level.) Moderate sedation is commonly performed using diazepines with or without narcotic agents. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation is considered a sufficient level of sedation.

Monitored anesthesia care (MAC) is directly provided by anesthesia personnel. MAC may include varying levels of sedation, analgesia, and anxiolysis. (If the patient loses consciousness and the ability to respond purposefully, the anesthesia care becomes general anesthesia.) Based on the American Society of Anesthesiologists’ (ASA) standard for monitoring, MAC should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. Monitored anesthesia care includes all aspects of anesthesia care – a pre-procedure visit, intra-procedure care and post-procedure anesthesia management. During MAC, the anesthesiology personnel provides or medically directs a number of specific services such as administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary.

Propofol is an agent that has been used increasingly to provide monitored anesthesia care for endoscopic procedures. Propofol is associated with a rapid onset of action and fast recovery from sedation. However, there have been concerns about potential side effects and safety when used by non-anesthesiologists. It has the potential to induce general anesthesia, and there is no pharmacologic antagonist to reverse its action. In many practice situations, it is common for propofol to be administered by anesthesiologists, whereas moderate sedation using diazepines with or without narcotics is usually administered by or under the supervision of the endoscopist.

Propofol (marketed as Diprivan® or as generic products) was first approved by the U.S. Food and Drug Administration in the late 1980s. The current FDA-approved label for Diprivan states that it is indicated for initiation and maintenance of Monitored Anesthesia Care (MAC) sedation, combined sedation and regional anesthesia, or Intensive Care Unit (ICU) sedation of intubated, mechanically ventilated patients in adults only. It is also approved for induction of general anesthesia in patients greater than or equal to 3 years of age, and maintenance of general anesthesia in patients greater than or equal to 2 months of age.

This policy only addresses anesthesia services for diagnostic or therapeutic endoscopic procedures.

• Prolonged or therapeutic endoscopy procedure requiring deep sedation, or
• Increased risk for complications due to severe comorbidity (ASA class III* or greater), or
• Morbid obesity (BMI >40), or
• Severe sleep apnea (oxygen and bi-pap required during sleep), or
• Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment), or
• Spasticity or movement disorder complicating procedure, or
• History or anticipated intolerance to standard sedatives, such as
  • Chronic opioid use
  • Chronic benzodiazepine use, or
• History of or anticipated intolerance to standard sedatives, or
• Patients who are pregnant, or
• Patients with active medical problems related to drug or alcohol abuse, or
• Acutely agitated uncooperative patients, or
• Patients with increased risk for airway obstruction due to anatomic variation, such as --
  • History of sleep apnea or stridor
  • Dysmorphic facial features
  • Oral abnormalities (e.g., macroglossia)
  • Neck abnormalities (e.g., neck mass)
  • Jaw abnormalities (e.g., micrognathia)
• Patients of extreme age, i.e., younger than age 12 or age 70 years or older

Use of monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopic procedures in patients at average risk related to use of anesthesia and sedation who are undergoing gastrointestinal endoscopic procedures, including endoscopic procedures used in screening.

Other indications for  Colonoscopy, Flexible Sigmoidoscopy, and CT Colonography, are discussed in a separate policy.

None

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

7/06/2009: Link to Colonoscopy, Flexible Sigmoidoscopy, and CT Colonography added to Policy Statement

04/21/2010: Policy statement revised to change “Patients age 70 or greater” to “Patients of extreme age.” Reworded statement regarding patients at average risk.

08/11/2010:  Policy reviewed; no changes.

04/18/2011: Policy statement updated to add examples of patients with increased risk for airway obstruction. Also added the following risk factors:  morbid obesity, severe sleep apnea, inability to follow simple commands, spasticity or movement disorder complicating procedure, or history or anticipated intolerance to standard sedatives. Added the American Society of Anesthesiologists (ASA) physical status classifications to the Policy Guidelines.

06/21/2011: Added the risk factor "Patients of extreme age, i.e., younger than age 12 or age 70 years or older" back to the policy statement.

02/24/2012:  Policy statement revised to change the BMI for morbid obesity from > 50 to >40.

05/09/2012:  Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes 

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