PAC Recommendation:

Wellmark’s Physician Advisory Committee (PAC) met by teleconference on Thursday, December 3, 2009, and discussed Wellmark’s current policy on nonpayment for Propofol administration for endoscopic procedures except under certain criteria.  The PAC voted to recommend that Wellmark examine a coding and payment mechanism that would better recognize Propofol administration for these procedures.  The PAC will meet again in February and will discuss Wellmark’s cardiology and oncology precertification programs.

Wellmark Response:

Wellmark has studied the recommendation and has the following response.

Wellmark believes that the recommendation for a payment mechanism is not feasible due to the following:

The administration of anesthesia for endoscopic procedures is not specific to the affected surgical codes. In fact, codes used for the administration of anesthesia crosswalk to 77 surgical codes. Since HIPAA does not allow the creation of payer specific codes, the additional Wellmark resources needed to implement any alternative payment mechanism would be extremely high. In addition, creating an alternative payment mechanism for Propofol administration would thwart the incentive to eliminate care that is not medically necessary. 

On July 1, 2009, Wellmark developed a medical policy which defines medical necessity guidelines for coverage of the routine assistance of an anesthesiologist or certified registered nurse anesthetist (CRNA) during gastrointestinal endoscopic procedures, including colonoscopies. Wellmark outlined a set of specific criteria that the patient must meet for the services to be considered medically necessary.

Based on provider feedback and the review of additional information, Wellmark has added the following payable conditions:

• 278.01-Morbid obesity
• 327.20-327.29-Organic sleep apnea
• 995.24-Failed moderate sedation during procedure
• V15.80-History of failed moderate sedation
• 993.*-Effects of air pressure
• 935.*-Foreign body in mouth, esophagus, and stomach
• Physical Status Modifiers P3-P6 Increased risk of complications due to a severe comorbidity
• Ages < 18 or > 70 years old

Wellmark has been monitoring the impact of this policy and has found the following:

• A total of 2,803 claims denied from July 1, 2009, through December 31, 2009.
• Of these, 378 claims, or 13 percent, were overturned:
  • 224 were adjusted based on changes made to the policies
  • 154 were adjusted following the review of submitted notes
• With the additional criteria being added, our denial rate has decreased by 15 percent (numbers calculated at the end of January), and our number of adjusted claims dropped significantly to 4.5 percent in January.

Wellmark believes this policy is still clinically valid and contains appropriate logic based on references.