Medical Policy: 07.01.45
Original Effective Date: July 2009
Reviewed: April 2015
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
This medical policy addresses anesthesia services during gastrointestinal endoscopic procedures. Anesthesia services include all services associated with the administration and monitoring of analgesia/anesthesia to a patient in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include moderate sedation, monitored anesthesia care, regional anesthesia and general anesthesia.
Moderate (conscious) sedation is generally used for both diagnostic and uncomplicated therapeutic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patient's ability to respond to stimulation. It includes pre-and post-sedation evaluations, administration of sedation, and monitoring of cardiorespiratory functions. Moderate sedation is commonly performed using diazepines with or without narcotics. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation is considered a sufficient level of sedation.
Monitored anesthesia care (MAC) may include varying levels of sedation, anxiolysis, and analgesia. Based on the American Society of Anesthesiologists' (ASA) standard for monitoring, MAC is to be provided by qualified anesthesia personnel who provide or medically direct a number of specific services such as administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary. Anesthesia care becomes general anesthesia if the patient loses consciousness and the ability to respond purposefully.
Moderate (conscious) sedation will continue to be reimbursed as an inherent part of the procedure when administered to average-risk adult patients undergoing general, diagnostic, uncomplicated, therapeutic endoscopy and colonoscopy. Moderate (conscious) sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care.
Monitored anesthesia care and general anesthesia may be considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician or the anesthesiologist/CRNA of any of the following circumstances:
A history of or anticipated intolerance to standard sedatives (i.e., patient is on chronic narcotic or benzodiazepine therapy, or has a neuropsychiatric disorder)
Increased risk of complications due to a severe co morbidity (American Society of Anesthesiologists [ASA] class III physical status or greater). See additional information below.
Prolonged or therapeutic endoscopic procedure requiring deep sedation
Age 70 years and older
Pediatric age group (younger than 18 years)
History of drug or alcohol abuse
Uncooperative or acutely agitated patient (i.e., delirium, organic brain disease, senile dementia)
Increased risk for airway obstruction due to anatomic variant including any of the following:
History of previous problems with anesthesia or sedation
History of stridor or sleep apnea
Dysmorphic facial features
Presence of oral abnormalities including but not limited to small oral opening (less than 3 cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or non-visible uvula
Neck abnormalities including but not limited to short neck, obesity involving the neck and facial structures, limited neck extension, decreased hyoid-mental distance (less than 3 cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis
Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or significant malocclusion.
The routine assistance of an anesthesiologist or a certified registered nurse anesthetist (CRNA) for average-risk adult patients undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered not medically necessary.
American Society of Anesthesiology Physical Status Classification:
Class I: Patient has no organic, physiologic, biochemical, or psychiatric disturbances. The pathologic process for which operation is to be performed is localized and does not entail systemic disturbance.
Class II: Mild or moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes
Class III: Severe, systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality.
Class IV: Severe systemic disorders that are already life threatening, not always correctable by operation.
Class V: The moribund patient who has little chance of survival but is submitted to operation in desperation.
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
Standards of Practice Committee, Lichtenstein DR, Jagganath S, Baron TH et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008 August;68(2):205-16.
Cohen LB, Delegge MH, Aisenberg J et al. AGA Institute Review of Endoscopic Sedation. Gastroenterology2007 August;133(2):675-701.
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017.
American Society of Anesthesiologists (ASA). Distinguishing monitored Anesthesia care ("MAC") from moderate sedation/analgesia. Amended October 21, 2009. Available online at: http://www.asahq.org.
Last accessed August 2011.
ECRI Institute. Sedasys System for Automated Administration of Propofol Sedation. ECRI Institute. Plymouth Meeting (PA). Health Technology Forecast. 2012 Mar 16. Available at: http:// www.ecri.org
Agostoni M, Fanti L, Gemma M et al. Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience. Gastrointest Endosc. 2011 Aug;74(2):266-75. Epub 2011 Jun 25.
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. 2011 Apr;73(4):710-7. Epub 2011 Feb 12.
Deepak A, Rockey D. Propofol for Screening Colonoscopy in Low-Risk Patients. JAMA Inern Med. Epub 2013 Jul 15.
Date Reason Action
August 2011 Annual review Policy renewed
August 2012 Annual review Policy renewed
July 2013 Annual review Policy renewed
April 2015 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
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and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.