Monitored Anesthesia Care during Gastrointestinal Endoscopy

POLICY NUMBER

L.7.02.403

DESCRIPTION

Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. Various levels of sedation and analgesia (anesthesia) may be used, depending on the patient’s condition and the procedure being performed. Monitored anesthesia care refers to a set of physician services, not a particular level of sedation. The services include the ability to convert a patient to general anesthesia (if needed) and to intervene in the event a patient’s airway becomes compromised.

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 is a set of anesthesia services defined by the type of anesthesia personnel present during a procedure, not specifically by the level of anesthesia needed. The American Society of Anesthesiologists (ASA) defined monitored anesthesia care, and the following is derived from ASA's statements:

"Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient’s clinical condition and/or the potential need to convert to a general or regional anesthetic.

Monitored anesthesia care includes all aspects of anesthesia care – a pre-procedure visit, intra-procedure care, and post-procedure anesthesia management. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

- Diagnosis and treatment of clinical problems that occur during the procedure- Support for vital functions- Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety- Psychological support and physical comfort- Provision of other medical services as needed to complete the procedure safely.

Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required."

Propofol has increasingly been used to provide monitored anesthesia care for endoscopic procedures. It is associated with a rapid onset of action and fast recovery from sedation. However, there are concerns about potential side effects and safety when used by non-anesthesiologists. Propofol 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.

In 1989, propofol (Diprivan®; AstraZeneca) was approved by the U.S. Food and Drug Administration through the premarket approval process for the induction and maintenance of anesthesia. The current FDA-approved label for Diprivan states that it is indicated for initiation and maintenance of monitored anesthesia care sedation, combined sedation, and regional anesthesia; the label also states that Diprivan is indicated for the sedation of adults in the intensive care unit who have been intubated or mechanically ventilated. It is also approved for the induction of general anesthesia in patients 3 years of age and older and maintenance of general anesthesia in patients 2 months of age and older.

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

POLICY

The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopic procedures when there is documentation by the endoscopist and anesthesiolgist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions are as follows:

• 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

• Documented sleep apnea, or

• Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment), or

• Spasticity or movement disorder complicating the procedure, or

• History or anticipated intolerance to standard sedatives, such as

  • Chronic opioid use

  • Chronic benzodiazepine use, or

• Individuals who are pregnant, or

• Individuals with active medical problems related to drug or alcohol abuse, or

• Acutely agitated uncooperative individuals, or

• Individuals with increased risk for airway obstruction due to anatomic variation, such as --

  • History of stridor

  • Dysmorphic facial features

  • Oral abnormalities (e.g., macroglossia)

  • Neck abnormalities (e.g., neck mass)

  • Jaw abnormalities (e.g., micrognathia)

• Individuals younger than 18 years or 70 years or older

The use of monitored anesthesia care is considered notmedically necessary for gastrointestinal endoscopic procedures in individuals 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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

*American Society of Anesthesiologists (ASA) classification system for assessing an individual before surgery:ASA I – A normal, healthy individualASA II – An individual with mild systemic diseaseASA III – An individual with severe systemic diseaseASA IV – An individual with severe systemic disease that is a constant threat to lifeASA V – A moribund individual who is not expected to survive without the operationASA VI – A declared brain-dead individual whose organs are being harvested

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

5/26/2009: Policy added.

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.

07/18/2013: Policy statement revised to change severe sleep apnea (oxygen and bi-pap required during sleep) to documented sleep apnea; history of sleep apnea was removed from the patients with increased risk for airway obstruction due to anatomic variation criteria; and patients of extreme age, i.e., younger than age 12 or age 70 years or older was changed to patients younger than 18 years or 70 years or older.

03/19/2014: Policy reviewed; no changes.

08/31/2015: Code Reference section updated for ICD-10.

06/01/2016: Policy number A.7.02.01 added. Policy Guidelines updated to add medically necessary definition.

12/06/2016: Policy description updated to define monitored anesthesia care according to the American Society of Anesthesiologists. Policy statements unchanged.

12/15/2017: Code Reference section updated to add new 2018 CPT codes 00731, 00732, 00811, 00812, and 00813 effective 01/01/2018.

01/10/2018: Policy reviewed; no changes.

01/11/2019: Policy description updated regarding monitored anesthesia care and indications for Diprivan®. Policy statements unchanged. Code Reference section updated to remove deleted CPT codes 00740 and 00810.

12/13/2019: Policy reviewed; no changes.

02/04/2021: Policy reviewed. Policy statements unchanged. Policy Guidelines updated regarding the ASA classification system and to change "Nervous/Mental Conditions" to "Mental Health Disorders."

04/06/2022: Policy reviewed; no changes.

01/18/2023: Policy reviewed. Policy section updated with minor wording changes and to remove duplicate statement. Policy Guidelines updated. Medical policy number changed from "A.7.02.01" to "L.7.02.403."

12/07/2023: Policy reviewed; no changes.

01/05/2024: Policy reviewed; no changes.

12/16/2024: Policy reviewed; no changes.

SOURCE(S)

Blue Cross & Blue Shield Association policy # 7.02.01  

CODE REFERENCE

This may not be a comprehensive list of procedure codesapplicable to this policy.

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

Covered Codes

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