Harvard Pilgrim HealthCare Medical Policy

Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

Subject: Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

Background: 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.

Policy and Coverage Criteria:

Harvard Pilgrim Health Care (HPHC) considers monitored anesthesia care (MAC) for elective upper and lower endoscopy for members with a higher risk for sedation-related complications as reasonable and medically necessary. Monitored anesthesia care for upper or lower gastrointestinal (GI) endoscopy is considered medically necessary for members presenting with ANY of the following:

• Member is under 18 years of age; OR
• Member is pregnant; OR
• Increased risk for complications due to severe co-morbidity corresponding to the American Society of Anesthesiologists (ASA) Physical Status Modifier of P2 or greater; OR
• Increased risk for airway obstruction due to anatomic variation, such as:
  • History of stridor;
  • Dysmorphic facial features;
  • Oral abnormalities (e.g. macroglossia);
  • Neck abnormalities (e.g. neck mass);
• OR
• Member has one of the following:
  • History of adverse reaction to sedation;
  • History of inadequate response to sedation;
  • Obstructive sleep apnea;
  • Morbid obesity (e.g. BMI >40)
  • Active or history of alcohol or substance abuse

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers Monitored Anesthesia Care for GI endoscopy as not medically necessary when above indications are not met.

Supporting Information:

In 2008, the American Society for Gastrointestinal Endoscopy published a guideline outlining appropriate use of sedation and anesthesia in GI endoscopy, updated in 2018. The guideline notes the routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate. Typical patient risk factors indicating monitored anesthesia it lists are significant medical conditions such as extremes of age; severe pulmonary, cardiac, renal, or hepatic diseases; pregnancy; history of substance abuse; uncooperative behavior;

HPHC Medical Policy

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MAC for GI Endoscopic Procedures

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HPHC policies are based on medical science, and written for the majority of people with a given condition. Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g.

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

potentially difficult airways for positive-pressure ventilation; and anatomy that is associated with more difficult intubation.

The American College of Gastroenterology states that healthy, low risk patients derive no increase in safety or procedural efficacy from anesthesiologist-administered sedation while incurring higher costs The American Society of Anesthesiologists Position on Monitored Anesthesia Care (2013) states that use of monitored anesthesia is indicated by a need for deeper sedation/analgesia than moderate sedation, such as with patient condition or nature of a procedure.

Guidelines:

• American Society of Anesthesiologists (ASA) Physical Status Modifiers
• P1 – A normal healthy patient
• P2 – A patient with mild systemic disease
• P3 – A patient with severe systemic disease
• P4 – A patient with severe systemic disease that is a constant threat to life
• P5 – A moribund patient who is not expected to survive without the operation
• P6 – A declared brain-dead patient whose organs are being removed for donor purposes