The Plan

Members undergoing certain endoscopic procedures may require different levels of sedation, depending on the procedure and their existing medical conditions.

General Anesthesia

One type of sedation where a physician or nurse anesthetist can induce a state of complete unconsciousness. This is different from conscious sedation, where a patient is awake but medications are given for pain and to help with relaxation.

The vast majority of patients undergoing endoscopies, where a small camera inserted to look for disease such as cancer or precancerous masses, are sedated with conscious sedation to make the procedure more tolerable.

This guideline provides criteria for members who may require general anesthesia, monitored anesthesia care (MAC), or deep sedation for both upper and lower gastrointestinal endoscopic procedures (i.e., upper endoscopy, colonoscopy). The treating provider should counsel the member on the appropriate anesthesia options and levels of risk.

Definitions

• Local Anesthesia is when a medication is used to induce an absence of pain/sensation to a specific region or part of the body.
• Minimal Sedation is also referred to as anxiolysis and is defined as the lowest level of drug-induced impaired cognition. Persons who are minimally sedated respond normally to commands and their respirations/cardiovascular system are unaffected. Examples of minimal sedatives include oral benzodiazepines.
• Moderate Sedation was historically known as "Conscious Sedation" and refers to a deeper depression of consciousness compared to minimal sedation. Persons who are moderately sedated will typically still respond to verbal commands, sometimes requiring tactile stimuli, and their respirations/cardiovascular system are unaffected. Examples of medications used for moderate sedation are IV benzodiazepines and opioids. During moderate sedation the responsible physician typically assumes the dual role of performing the procedure and supervising the sedation (an anesthesia provider is not involved with moderate sedation).
• Monitored Anesthesia Care (MAC) is a combination of local anesthesia together with sedation and/or analgesia, in a setting monitored by a trained anesthesiologist (physician), an certified registered nurse anesthetist (CRNA), or certified anesthesiologist assistants. While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the qualified anesthesia provider of MAC is focused exclusively on the member for airway, hemodynamic and physiologic changes. Furthermore, the provider of MAC must be prepared and qualified to convert to general anesthesia. As described by American Society of Anesthesiologists, Monitored Anesthesia Care is a physician 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.
• Deep Sedation/Analgesia is part of a continuum from monitored anesthesia care to general anesthesia and results in significant central nervous system depression, where patients are no longer conscious and are more difficult to arouse. They will typically respond to painful stimuli but not to verbal or simple tactile stimuli. The respiratory system is depressed and they may need some ventilatory support. Examples of medications used for deep sedation are IV benzodiazepines, opioids, propofol, ketamine, etomidate, and dexmedetomidine.
• General Anesthesia is the deepest form of sedation, where there is complete loss of consciousness and no arousability to stimuli. Cardiovascular and respiratory function are often impaired and may require monitoring and assistance such as ventilatory support. General anesthesia always requires monitoring by an anesthesia provider.

American Society for Anesthesia Physical Status Classes

Are used to risk stratify patients prior to procedures. The categories were developed and defined by the American Society for Anesthesiologists and are as follows:

1. ASA Physical Status Class I: A normal, healthy person
2. ASA Physical Status Class II: A person with mild systemic disease without functional limitations, including but not limited to:
   • Current smoker
   • Social alcohol drinker
   • Pregnancy
   • Obesity (BMI <40)
   • Well-controlled diabetes mellitus or hypertension
   • Mild lung disease
3. ASA Physical Status Class III: A person with severe systemic disease resulting in substantive functional limitations, including but not limited to:
   • Poorly controlled diabetes mellitus or hypertension
   • Chronic obstructive pulmonary disease (COPD)
   • Morbid obesity (BMI ≥40)
   • Active hepatitis
   • Alcohol dependence or abuse
   • Implanted pacemaker
   • Moderate reduction of ejection fraction
   • End stage renal disease (ESRD) undergoing regularly scheduled dialysis
   • Premature infant with post-conceptual age < 60 weeks
   • History (>3 months) of myocardial infarction (MI), cerebrovascular accident (CVA or stroke), transient ischemic attack (TIA or mini-stroke), or coronary artery disease (CAD)/stents.
4. ASA Physical Status Class IV: A person with severe systemic disease that is a constant threat to life; including but not limited to:
   • Recent (< 3 months) MI, CVA, TIA, or CAD/stents
   • Ongoing cardiac ischemia
   • Severe valve dysfunction
   • Severe reduction of ejection fraction
   • Sepsis
   • Disseminated intravascular coagulation (DIC)
   • ESRD not undergoing regularly scheduled dialysis
5. ASA Physical Status Class V: A moribund person who is not expected to survive without the operation; including but not limited to:
   • Ruptured abdominal/thoracic aneurysm
   • Massive trauma
   • Intracranial bleed with mass effect
   • Ischemic bowel in the face of significant cardiac pathology
   • Multiple organ/system dysfunction
6. ASA Physical Status Class VI: A declared brain-dead person whose organs are being removed for donor purposes.

Modified Mallampati Classification

Is used to assess airways and risk for difficult tracheal intubation. The original Mallampati Classification has class I-III. The modified Mallampati Classification has class I-IV.

1. Class 0: Ability to see any part of the epiglottis upon mouth opening and tongue protrusion
2. Class I: Soft palate, fauces, uvula, pillars visible
3. Class II: Soft palate, fauces, uvula visible
4. Class III: Soft palate, base of uvula visible
5. Class IV: Soft palate not visible at all

Endoscopy

Refers to a procedure where a small camera is inserted to visualize internal parts of the body. Examples include the following:

• Colonoscopy (looking at the colon)
• Sigmoidoscopy (looking at the sigmoid portion of the colon)
• Esophagoduodenoscopy (i.e., EGD, where the upper GI system is visualized)

Clinical Indications

The Plan considers general anesthesia, MAC, or deep sedation requiring anesthesiologist or anesthetist attendance medically necessary for use in upper or lower gastrointestinal endoscopy in "high-risk" members, defined as those with ONE of the following criteria:

1. Significant medical condition, as defined by at least ONE of the following:
   • ASA Physical Status Class III-V; or
   • Note: In specific cases of ETOH dependence/abuse, stable chronic ETOH dependence can be performed under moderation sedation for ASA III. As per American Society of Gastrointestinal Endoscopy minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Although alcohol dependence or abuse falls within ASA III, the concern for complications and the request for higher level of anesthesia is appropriate when alcohol has affected other organs (e.g., cirrhosis, end-stage liver disease), or systemic effects such as acute alcohol intoxication.
   • Pregnancy; or
   • Epilepsy; or
   • Age less than 18; or
   • Age greater than 70, one other criteria must also be met under 1-4.
2. Risk for airway compromise, as defined by at least ONE of the following:
   • Current evidence of obstructive sleep apnea or stridor; or
   • Dysmorphic facial features, such as Pierre-Robin or Down syndrome; or
   • Modified Mallampati classification Class III-IV; or
   • Neck abnormalities, such as neck obesity, short neck, limited neck extension, cervical spine instability, cervical spine disease or trauma, neck mass, tracheal deviation, advanced rheumatoid arthritis (risk of cervical instability), cranial nerve IX or X dysfunction;
   • Jaw abnormalities, such as micrognathia, retrognathia, trismus, significant macro-occlusion; or
   • Morbid obesity (defined as body mass index [BMI] >40 or >35 with hypertension, coronary artery disease, obstructive sleep apnea, or Type 2 diabetes).
3. Anticipated intolerance to standard sedatives, as defined by at least ONE of the following:
   • Previous reaction or complication with sedation or anesthesia; or
   • Opiate, sedative, or hypnotic dependence or tolerance due to chronic use; or
   • Alcohol or substance abuse.
4. Situations where deep sedation or general anesthesia may be required, as defined by at least ONE of the following:
   • Uncooperative or combative patients (e.g., those with dementia, psychiatric disorders, or young children); or
   • Complex or prolonged procedures or invasive therapeutic endoscopies, such as the following:
     1. Endoscopic retrograde cholangiopancreatography [ERCP]
     2. Endoscopic ultrasound [EUS]
     3. Esophageal stenting
     4. Emergency therapeutic procedures such as acute GI bleeding
     5. A patient with a complex condition who may experience more pain or discomfort
     6. A patient with a history of prolonged procedures or history of difficult intubation
     7. A patient with a long, or tortuous, colon
     8. A patient requiring a repeat colonoscopy due to the inability to be sedated with conscious sedation at the initial colonoscopy or due to the result of another issue from the initial colonoscopy that a repeat was medically warranted.

Experimental or Investigational / Not Medically Necessary

Sedation requiring anesthesiologist or anesthetist care (e.g., general anesthesia, MAC, or deep sedation) is not considered medically necessary in members with an "average risk" of surgical complications, as defined as ASA Class I-II and not meeting "high-risk" criteria above, who are undergoing standard upper or lower endoscopic procedures. These members should undergo procedures with moderate sedation/analgesia as indicated and provided by the endoscopist, where it is not medically necessary for an anesthesiologist to be present.