Medical Policy: 07.01.45
Original Effective Date: July 2009
Reviewed: March 2017
Revised: March 2016
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. The class of drugs used for conscious sedation are designed to provide for sedation, hypnosis-like compliance, relieve anxiety, muscle relaxation, and anticonvulsant activity. The “side effect” that medical professionals most like about these drugs is that they generally induce anterograde amnesia (prevent memory by blocking the acquisition and encoding of new information). In other words, medical professionals like these drugs because most people will not remember what happens to them while under their effect even though they are “awake.” Not all drugs used for conscious sedation have amnesic effects.
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:
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.
It would not be advisable to use moderate sedation/monitored anesthesia care when conscious sedation would be efficient for the patient and/or the procedure. The higher risk associated with monitored anesthesia care makes the use less desirable when either sedation is efficient for the procedure.
American Society of Anesthesiology Physical Status Classification:
Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.
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