Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2017 POLICY LAST UPDATED: 10|04|2023

OVERVIEW The intent of this policy is to address anesthesia services for diagnostic or therapeutic procedures performed in the outpatient setting. 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. This policy addresses the monitored anesthesia care (MAC) and refers to the anesthesia personnel present during a procedure and does not implicitly indicate the level of anesthesia needed.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Prior authorization review is not required.

POLICY STATEMENT Medicare Advantage Plans and Commercial Products Monitored Anesthesia Care (MAC) CPT codes 00100-01999: Monitored anesthesia care is covered and separately reimbursed.

Moderate (Conscious) Sedation: CPT codes 99155 – 99157 Moderate sedation when rendered by a provider other than the provider performing the diagnostic or therapeutic service, is covered and separately reimbursed.

CPT codes 99151 – 99153 Moderate sedation when rendered by the same provider who is performing the diagnostic or therapeutic service, is covered but not separately reimbursed.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable anesthesia/surgery services coverage/benefits.

BACKGROUND The American Society of Anesthesiologists (ASA) has defined MAC as:

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
Payment Policy | Anesthesia Services

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• Support of 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.

MAC may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of MAC 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.

In 2004, the ASA defined 4 levels of sedation/analgesia as follows:

I. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilator and cardiovascular function are unaffected. II. Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. III. Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. IV. General anesthesia is a drug-induced depression of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilator function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Multiple diagnostic and therapeutic procedures performed in the outpatient setting, including endoscopy, colonoscopy, bronchoscopy, and interventional pain management procedures, rely on some degree of sedation of anxiolysis and pain control. Regardless of sedation depth, sedation and anesthesia services that are provided in outpatient settings should by administered by qualified and appropriately trained personnel. Moderate sedation is generally sufficient for many diagnostic and uncomplicated therapeutic procedures. Moderate sedation using benzodiazepines, with or without narcotics, is frequently administered under the supervision of the proceduralist.

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescue patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia.

According to the American Society of Anesthesiologists’ (ASA) standard for monitoring, MAC should be provided by qualified anesthesia personnel, including physicians and nurse specialists. By this standard, the personnel must be in addition to the proceduralist and must be present continuously to monitor the patient

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

and provide anesthesia care. For patients at high risk of an unsuccessful procedure under moderate sedation, this allows for the safe continuation of the procedure under deep sedation or general anesthesia by trained personnel.

Moderate sedation can be achieved using pharmacologic agents for sedation, anxiolysis, and analgesia. A frequently used combination is an opioid and benzodiazepine, for example fentanyl with midazolam, at doses individualized to obtain the desired sedative effect. Other combinations have also been utilized for this purpose. While both benzodiazepines and opioids can cause respiratory depression, effective reversal agents exist for both.

Propofol is an agent that has been increasingly used to provide sedation for 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. Propofol has the potential to induce general anesthesia, and there is no pharmacologic antagonist to reverse its action. When used as moderate sedation, propofol may be administered by anesthesia personnel or under the direction of the proceduralist. ASA has offered practice guidelines for the provision of sedation by non-anesthesiologists, stating that personnel must be prepared to respond to deep sedation and loss of airway protection should these complications inadvertently occur during sedation.

CODING Medicare Advantage Plans and Commercial Products The following codes are covered: Monitored Anesthesia Care (MAC) Coding: Anesthesia codes 00100-01999

Moderate (Conscious) Sedation Coding:
Moderate (Conscious) Sedation performed by a second provider 99155 Moderate sedation services provided by a physician or other qualified health care professional other

than the physician or other qualified health care professional performing the diagnostic or

therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger

than 5 years of age 99156 Moderate sedation services provided by a physician or other qualified health care professional other

than the physician or other qualified health care professional performing the diagnostic or

therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5

years or older 99157 Moderate sedation services provided by a physician or other qualified health care professional other

than the physician or other qualified health care professional performing the diagnostic or

therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List

separately in addition to code for primary service)

The above codes, when performed in a facility setting are eligible for separate reimbursement by a second provider in situations where a patient’s medical condition requires the dedication of a separate physician. This applies to the following specialties: • Emergency medicine (specialty code 093) • Critical Care (specialty code 079) • Anesthesia specialties • Another physician who is credentialed/qualified to perform these services

The following codes are not separately reimbursed: 99151 Moderate sedation services provided by the same physician or other qualified health care professional

performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

an independent trained observer to assist in the monitoring of the patient’s level of consciousness

and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age 99152 Moderate sedation services provided by the same physician or other qualified health care professional

performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of

an independent trained observer to assist in the monitoring of the patient’s level of consciousness

and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 99153 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) G0500 Moderate sedation services provided by the same physician or other qualified health care professional

performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an

independent trained observer to assist in the monitoring of the patient’s level of consciousness and

physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional

time may be reported with 99153, as appropriate)

RELATED POLICIES Not applicable

PUBLISHED Provider Update, December 2023 Provider Update, March 2020 Provider Update, May 2018 Provider Update, March 2017 Provider Update, August 2016 Provider Update, January 2016

REFERENCES

1. American Society of Anesthesiologists (ASA). Position on monitored anesthesia care. Amended October 16, 2013. http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards- guidelines/position-onmonitored- anesthesia-care.pdf. Accessed October 6, 2016.
2. American Society of Anesthesiologists (ASA). Distinguishing monitored Anesthesia care ("MAC") from moderate sedation/analgesia. Amended October 21, 2009 and reaffirmed October 2013. http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/distinguishing- monitoredanesthesia-care-from-moderate-sedation-analgesia.pdf. Accessed October 6, 2016.
3. American Society of Anesthesiologists (ASA). Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. http://www.asahq.org/~/media/sites/asahq/files/public/resources/standardsguidelines/continuum-of- depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf. Accessed October 6,
5. American Society of Anesthesiologists (ASA). Statement on qualifications of anesthesia provided in the officebased setting. Amended October 2014. http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/statement- onqualifications-of-anesthesia-providers-in-the-office-based-setting.pdf. Accessed October 6, 2016.
6. Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology. Aug 2007;133(2):675-701. PMID 17681185
7. Enestvedt BK, Eisen GM, Holub J, et al. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures? Gastrointestinal Endoscopy. Mar 2013;77(3):464-471. PMID 23410699

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

7. Agostoni M, Fanti L, Gemma M, et al. Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience. Gastrointest Endosc. Aug 2011;74(2):266-275. PMID 21704990
8. Berzin TM, Sanaka S, Barnett SR, et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc. Apr 2011;73(4):710-717. PMID 21316669
9. Coté GA, Hovis RM, Ansstas MA, et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol. Feb 2010;8(2):137-142. PMID 19607937

10. Singh H, Poluha W, Cheung M, et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev. 2008(4):CD006268. PMID 18843709

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS