Medical Policy: 07.01.45 

Original Effective Date: July 2009 

Reviewed: March 2020 

Revised: March 2020 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

Benefit Application:

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.

 

Description:

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.

 

Abbreviations used: ASA: American Society of Anesthesiologists, BMI: body mass Index, CHF: congestive heart failure, COPD: chronic obstructive pulmonary disease.

  • ASA 1: A normal healthy patient. Example: Fit, nonobese (BMI under 30), a nonsmoking patient with good exercise tolerance.
  • ASA 2: A patient with a mild systemic disease. Example: Patient with no functional limitations and a well-controlled disease (e.g., treated hypertension, obesity with BMI under 35, frequent social drinker or is a cigarette smoker).
  • ASA 3: A patient with a severe systemic disease that is not life-threatening. Example: Patient with some functional limitation as a result of disease (e.g., poorly treated hypertension or diabetes, morbid obesity, chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, implanted pacemaker).
  • ASA 4: A patient with a severe systemic disease that is a constant threat to life. Example: Patient with functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly controlled COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke.
  • ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not expected to survive beyond the next 24 hours without surgery. Examples: ruptured abdominal aortic aneurysm, massive trauma, and extensive intracranial hemorrhage with mass effect.  
  • ASA 6: A brain-dead patient whose organs are being removed with the intention of transplanting them into another patient.
     

 

Guidelines and Position Statements

American Society for Gastrointestinal Endoscopy

In the 2018 American Society for Gastrointestinal Endoscopy (ASGE) guidelines for sedation and anesthesia in GI endoscopy;

 

Guideline for anesthesia provider assistance during GI endoscopy
  • Anesthesia provider assistance should be considered in the following situations:
  • Prolonged or therapeutic endoscopic procedures requiring deep sedation
  • Anticipated intolerance to standard sedatives
  • Increased risk for adverse event because of severe comorbidity
  • (ASA class IV or V)
  • Increased risk for airway obstruction because of anatomic variant 

 

The guideline further states that individuals with medical comorbidities may require MAC. Many factors go into determining whether the assistance of MAC is necessary.

 

Risk factors include: 

Significant medical conditions such as extremes of age; severe pulmonary, cardiac, renal, or hepatic disease; pregnancy; the abuse of drugs or alcohol; uncooperative patients; a potentially difficult airway for positive-pressure ventilation; and individuals with anatomy that is associated with more difficult intubation.

 

Prior Approval:

Not applicable

 

Policy:

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 (examples include patients with adhesions after abdominal surgery, stent placement in the upper GI tract, and complex therapeutic procedures such as plication of the cardioesophageal junction. Polyp removal or combination upper and lower endoscopy completed simultaneously would not be considered a prolonged procedure).
  • Age 70 years and older
  • Pediatric age group (younger than 18 years)
  • Pregnancy
  • Drug or alcohol abuse
  • Uncooperative or acutely agitated patient (i.e., delirium, organic brain disease, senile dementia)
  • Morbid obesity
  • Increased risk for airway obstruction due to anatomic variant including any of the following:
    • History of previous problems with anesthesia or sedation
    • Stridor 
    • 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.

 

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.

 

Policy Guidelines

American Society of Anesthesiology Physical Status Classification:

 

Abbreviations used: ASA: American Society of Anesthesiologists, BMI: body mass Index, CHF: congestive heart failure, COPD: chronic obstructive pulmonary disease.

  • ASA 1: A normal healthy patient. Example: Fit, nonobese (BMI under 30), a nonsmoking patient with good exercise tolerance.
  • ASA 2: A patient with a mild systemic disease. Example: Patient with no functional limitations and a well-controlled disease (e.g., treated hypertension, obesity with BMI under 35, frequent social drinker or is a cigarette smoker).
  • ASA 3: A patient with a severe systemic disease that is not life-threatening. Example: Patient with some functional limitation as a result of disease (e.g., poorly treated hypertension or diabetes, morbid obesity, chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, implanted pacemaker).
  • ASA 4: A patient with a severe systemic disease that is a constant threat to life. Example: Patient with functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly controlled COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke.
  • ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not expected to survive beyond the next 24 hours without surgery. Examples: ruptured abdominal aortic aneurysm, massive trauma, and extensive intracranial hemorrhage with mass effect.  
  • ASA 6: A brain-dead patient whose organs are being removed with the intention of transplanting them into another patient.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 00731 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
  • 00732 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
  • 00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
  • 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
  • 00813 Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum

 

Selected References:

  • 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.
  • 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. Last accessed August 2012.
  • Deepak A, Rockey D. Propofol for Screening Colonoscopy in Low-Risk Patients. JAMA Inern Med. Epub 2013 Jul 15.
  • New England Journal of Medicine, Journal Watch April 13 2012 and JW Gastroenterol Feb 17 2012). Routine Propofol Sedation Increases Risk During Colonoscopy
  • 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: 1004-17.
  • Heuss LT, Schnieper P, Drewe J, et al. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologists: a prospective observational study of more than 2000 cases. Gastrointest Endosc 2003; 57: 664-71.
  • Vargo, J., Niklewski, P., Williams, J., Martin, J., Faigel, D. Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. (2017) Gastrointestinal Endoscopy, (85), 101-108.
  • American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration 2016
  • American Society of Anesthesiologists (ASA). Position on monitored anesthesia care (Amended October 16, 2013). 2013; 
  • ECRI Institute, Health Technology Assessment Special Report. Patient selection criteria for surgery and interventional pain management procedures performed in ambulatory settings. April 2017.
  • Vargo JJ, Nikliewski PJ, Williams JL, et al. Patient safety by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc 2017;85: 101-8.
  • ASGE Standards of Practice Committee. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy, Vol 87 No. 2. (2018)
  • Hocevar LA, Fitzgerald BM. American Society of Anesthesiologists Staging. [Updated 2019 Nov 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.  

 

Policy History:

  • March 2020 - Annual Review, Policy Revised
  • March 2019 - Annual Review, Policy Renewed
  • March 2018 - Annual Review, Policy Revised
  • March 2017 - Annual Review, Policy Renewed
  • March 2016 - Annual Review, Policy Revised
  • April 2015 - Annual Review, Policy Renewed
  • July 2013 - Annual Review, Policy Renewed
  • August 2012 - Annual Review, Policy Renewed
  • August 2011 - 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 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.

 

*CPT® is a registered trademark of the American Medical Association.