Anthem Blue Cross Connecticut CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation Form

This document addresses the medical necessity of anesthesia services. Anesthesia services include all services associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation (“conscious sedation”), and local infiltration or topical application. This document does not address anesthesia services performed during gastrointestinal endoscopic procedures.

Note: Please see the following documents for additional information:

• CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
• CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
• CG-MED-65 Manipulation Under Anesthesia
• CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures

Note: This document does not address whether or not reimbursement is provided for the anesthesia service and is not intended to explain the billing and reimbursement of anesthesia.

Clinical Indications

Medically Necessary:

General Anesthesia or Regional Anesthesia
Administration of general or regional anesthesia is considered medically necessary when both of the following criteria are met:

1. The services are provided by an individual other than the attending physician performing the procedure; and
2. Alternative types of anesthesia, sedation, or analgesia are not appropriate.

If general or regional anesthesia is requested for a procedure typically not requiring either of these levels of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.

Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:

1. MAC is requested by the attending physician; and
2. The services are provided by an individual other than the attending physician performing the procedure; and
3. Qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists) administering monitored anesthesia care are continuously present to monitor the individual and provide anesthesia care; and
4. The individual's medical condition requires medical direction or supervision of the anesthetic to ensure control of the sedation, medication, and airway, and to prevent sudden changes in condition from disrupting the procedure and placing the individual at risk; and
5. Constant monitoring of the individual’s vital signs is provided to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the procedure may become more extensive, or result in unforeseen complications, requires comprehensive monitoring or anesthetic intervention; and
6. Appropriate documentation is available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.

Anesthesia Services including MAC for Surgical Procedures
For surgical procedures which do not usually require anesthesia services, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented. The medical condition must be significant enough to impact the need to provide anesthesia services including MAC. Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Moderate (“Conscious”) Sedation
Moderate sedation (“conscious sedation”) ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Local Anesthesia
The administration of local anesthesia is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Standby Anesthesia Services
Standby anesthesia service is when the anesthesiologist would be immediately available if a clinical need should arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia.

Not Medically Necessary:

Anesthesia services are considered not medically necessary for all other indications.