Anthem Blue Cross Connecticut CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Form

This document addresses the medical necessity of the use of monitored anesthesia care during gastrointestinal endoscopic procedures. This document does not address whether or not reimbursement is provided for the anesthesia service and it is not intended to guide the billing and reimbursement of anesthesia services.

Note: Please see the following related document for additional information:

• CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation

Clinical Indications

Medically Necessary:

Monitored Anesthesia Care (for definition, see Discussion below)

Monitored anesthesia care is considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician or the anesthesiologist that demonstrates any of the following higher risk situations exist:

• Prolonged or therapeutic endoscopic procedure requiring deep sedation such as endoscopic retrograde cholangiopancreatography (ERCP) or repeat colonoscopy due to tortuous colon; or
• A history of or anticipated poor response due to cross tolerance or paradoxical reaction to standard sedatives used during moderate (conscious) sedation specifically due to narcotics or benzodiazepines; or
• Increased risk for complication due to severe comorbidity (American Society of Anesthesiologists [ASA] class III physical status or greater. See Appendix for physical status classifications); or
• Individuals over 70; or
• Individuals under the age of 18; or
• Pregnancy; or
• History of drug or alcohol abuse; or
• Uncooperative or acutely agitated individuals (for example, delirium, organic brain disease, senile dementia); or
• Increased risk for airway obstruction due to anatomic variant including any of the following:
  • History of previous problems with anesthesia or sedation; or
  • History of stridor or sleep apnea; or
  • Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21; or
  • Presence of oral abnormalities including but not limited to a small oral opening (less than 3cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or a non-visible uvula (not visible when tongue is protruded with individual in sitting position [for example, Mallampati class greater than II]); or
  • Neck abnormalities including but not limited to short neck, obesity involving the neck and facial structures, limited neck extension, decreased hyoid-mental distance (less than 3cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis; or
  • Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or significant malocclusion.

The routine assistance of an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for individuals meeting the above criteria who are undergoing gastrointestinal endoscopic procedures is considered medically necessary.

Not Medically Necessary:

Monitored anesthesia care is considered not medically necessary when the above criteria are not met.

The routine assistance of an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for individuals not meeting the above criteria who are undergoing gastrointestinal endoscopic procedures is considered not medically necessary.