Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 07|01|2018 POLICY LAST REVIEWED: 01|21|2026 OVERVIEW
Monitored Anesthesia Care (MAC) is anesthesia care involves a drug-induced depression of consciousness during which the patient may respond purposefully to verbal commands (either alone or accompanied by light tactile stimulation) and requires monitoring of the patient by a practitioner who is qualified to administer anesthesia. Typically, cardiovascular function is maintained, and no interventions to maintain a patent airway are required (spontaneous ventilation is usually adequate). Indications for MAC depend on the nature of the procedure, the patient’s clinical condition, and/or the potential need to convert to a general or regional anesthetic. The intent of this policy is to address MAC services for gastrointestinal endoscopic diagnostic or therapeutic procedures performed in the outpatient setting. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Monitored anesthesia care (MAC) for gastrointestinal endoscopic procedures is a covered service for elective upper and lower endoscopy for members with a higher risk for sedation-related complications. Member’s medical records must document that services are medically necessary for the care provided. Blue Cross Blue Shield of Rhode Island (BCBSRI) maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available to BCBSRI upon request. Failure to produce the requested information may result in denial or retraction of payment. 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 Use of monitored anesthesia care for upper or lower gastrointestinal (GI) endoscopy is considered appropriate in the following circumstances: • Member is under 18 years of age; OR • Member is over 70 years of age; OR • Member is pregnant; OR • Member is acutely agitated and/or uncooperative; OR • Increased risk for complications due to severe comorbidity (American Society of Anesthesiologists (ASA) class III, IV, or V) (refer to ASA’s Physical Status Classification System, in the Coding section below); OR • There is an increased risk for airway obstruction due to anatomic variation, such as: o History of stridor; Medical Coverage Policy | Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

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

o Dysmorphic facial features; o Oral abnormalities (e.g. macroglossia); o Neck abnormalities (e.g. neck mass); o Jaw abnormalities (e.g. micrognathia); OR • Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation, such as;
o endoscopy in members with adhesions after abdominal surgery o endoscopic retrograde cholangiopancreatography o stent placement in the upper gastrointestinal tract o complex therapeutic procedures, such as plication of the cardioesophageal junction; OR • Member has one of the following: o History of adverse reaction to sedation; o History of inadequate response to sedation; o History or anticipated intolerance to standard sedatives, such as ▪ Chronic opioid use ▪ Chronic benzodiazepine use o Documented sleep apnea; o Morbid obesity (e.g. BMI > 40kg/m2) o Active medical problems related to drug or alcohol abuse o Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment) o Spasticity or movement disorder complicating the procedure • Anticipated prolonged procedure where therapeutic intervention may be involved

The use of MAC should be administered in a licensed facility administering all types of anesthesia, other than general anesthesia, an anesthesiologist, a certified registered nurse anesthetist, or a physician shall administer anesthesia. Furthermore, the person administering anesthesia shall not function in any other capacity during the surgical procedure.

In October 2023, the American Society of Anesthesiologists (ASA) updated their statements distinguishing MAC from moderate sedation/analgesia (conscious sedation).

ASA Statements Regarding Moderate Sedation During Moderate Sedation, a qualified provider supervises or personally administers sedative and/or analgesic medications such that the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. This can allay patient anxiety and limit pain during a diagnostic or therapeutic procedure. During Moderate Sedation, the responsible provider typically assumes the dual role of performing the procedure and supervising the sedation. Such drug-induced depression of a patient’s level of consciousness to a “moderate” level of sedation, as defined in the Centers for Medicare & Medicaid Services Conditions of Participation, is intended to facilitate the successful performance of the diagnostic or therapeutic procedure while providing patient comfort and cooperation. Those providing moderate sedation must be qualified to recognize “deep” sedation, manage its consequences, and adjust the level of sedation to a “moderate” or lesser level. The continual appraisal of the effects of sedative or analgesic medications on the level of consciousness and on cardiac and respiratory function is an integral element of this service.

ASA Statements Regarding Monitored Anesthesia Care (MAC) MAC as a specific anesthesia service performed by a qualified (trained) anesthesia provider, for a diagnostic or therapeutic procedure. Indications for MAC include, but are not limited to, the nature of the procedure, the patient’s clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic). Monitored Anesthesia Care includes all aspects of anesthesia care—a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. During MAC, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

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

• Preprocedural assessment and management of patient comorbidity and periprocedural risk • Diagnosis and treatment of clinical problems that occur during the procedure
• Support of vital functions inclusive of hemodynamic stability, airway management, and appropriate management of the procedure induced pathologic changes as they affect the patient’s coexisting morbidities • 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 • Postoperative medical and pain management

MAC may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesia provider of monitored anesthesia care must be prepared to manage all levels of sedation up to and including general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of the procedure and patient positioning. Please also refer to ASA’s Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.

MAC can be distinguished from Moderate Sedation in several ways. Proceduralists providing moderate sedation may have their attention divided between their primary focus, the procedure, and secondary focus, patient sedation. Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s respiratory or cardiovascular functions or ability to maintain airway integrity. A provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC. These components of MAC are unique aspects of an anesthesia service that are not part of Moderate Sedation. In addition, MAC includes an array of post-procedure responsibilities beyond the expectations of practitioners providing Moderate Sedation, including assuring a return to baseline consciousness, relief of pain, management of adverse physiological responses or side effects from medications administered during the procedure, as well as the diagnosis and treatment of co-existing medical problems.

MAC allows for the safe administration of a depth of sedation in excess of that provided during Moderate Sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during a procedure provides maximal flexibility in matching sedation level to a patient’s needs and procedural requirements. In situations where the procedure is more invasive, or when the patient is especially fragile, optimizing sedation level while maintaining cardiopulmonary function is necessary to achieve ideal procedural conditions.

In summary, MAC is an anesthesia service that is clearly distinct from Moderate Sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.

CODING Medicare Advantage Plans and Commercial Products: The following CPT code(s) are covered:
00731 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified 00732 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP) 00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy 00813 Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum

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

Providers should report all services using the most up-to-date industry-standard procedure, revenue, diagnosis codes, and modifiers where applicable, including Physical Status Modifiers P1 though P6 based on the ASA Classification I through VI, as follows:

Physical Status Modifier Description P1 ASA Class I: A normal, healthy individual P2 ASA Class II: An individual with mild systemic disease P3 ASA class III: An individual with severe systemic disease P4 ASA class IV: An individual with severe systemic disease that is a constant threat to life P5 ASA class V: A moribund individual who is not expected to survive without the operation P6 ASA Class VI: A declared brain-dead individual whose organs are being harvested

RELATED POLICIES Anesthesia Services

PUBLISHED Provider Update, March 2026 Provider Update, March 2025 Provider Update, April 2024 Provider Update, February 2023, June 2023 Provider Update, January 2022

REFERENCES

1. American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. Amended October 13, 20. 2021; https://www.asahq.org/standards-and-practice- parameters/statement-on-anesthetic-care-during-interventional-pain-procedures-for-adults. Accessed September 29, 2025.
2. American Society of Anesthesiologists (ASA). Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia (Last Amended on October 23, 2019). 2019; https://www.asahq.org/standardsand-guidelines/continuum-of-depth-of-sedation-definition-of-general- anesthesia-and-levels-of-sedationanalgesia. Accessed September 24, 2025.
3. American Society of Anesthesiologists (ASA). Distinguishing monitored Anesthesia care (MAC) from moderate sedation/analgesia (Last Amended October 18, 2023). 2023; https://www.asahq.org/standards- and-practice-parameters/statement-on-distinguishing-monitored-anesthesia-care-from-moderate-sedation- analgesia. Accessed October 1, 2025.
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5. American Society of Anesthesiologists (ASA). Statement on safe use of propofol (Amended October 23, 2024). 2024; https://www.asahq.org/standards-and-practice-parameters/statement-on-safe-use-of- propofol. Accessed September 26, 2025.
6. American Society for Gastrointestinal Endoscopy (ASGE). Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2025;91(2):223-240. doi:10.1016/j.gie.2024.12.001. https://www.guidelinecentral.com/guideline/9437.
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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

8. Dumonceau, JM., Riphaus, A., Schreiber, F., et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates Guideline – Updated June 1015. Endoscopy. 2015; 47(12): 1175-1189. doi:10.1055/s-0034-1393414
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24. Kawasaki T, et al. Safe anesthetic care in gastrointestinal endoscopy: emerging drugs and airway devices. Curr Opin Anaesthesiol. 2024;37(3):289-296. doi:10.1097/ACO.0000000000001234

    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