Anesthesia services for routine gastrointestinal endoscopic procedures
These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is not required. However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.
Anesthesia services for routine upper and/or lower gastrointestinal endoscopic procedures are generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
- Minimal sedation.
- Moderate (conscious) sedation during standard upper or lower gastrointestinal (GI) endoscopy is covered as a component of the endoscopic procedure (e.g., therapeutic endoscopy, colonoscopy) when administered to an average-risk patient (i.e., American Society of Anesthesiologists Physical Status Classification System - Class I or II). This does not apply to minimal sedation (anxiolysis), monitored anesthesia (i.e., deep sedation), or general anesthesia. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation is considered a sufficient level of sedation.
- Other types of anesthesia services including general anesthesia, monitored anesthesia (i.e., deep sedation) and monitored anesthesia care (MAC) may be considered medically necessary during routine upper and/or lower gastrointestinal endoscopic procedures when there is documentation by the operating physician and/or the anesthesiologist of any of the following situations:
- Patient’s condition requires unusually prolonged or therapeutic endoscopic procedure requiring deep sedation e.g., endoscopic retrograde cholangiopancreatography (ERCP), balloon enteroscopy, foreign body extraction from the upper gastrointestinal tract, percutaneous endoscopic gastrojejunostomy and direct percutaneous jejunostomy, esophageal stenting, endoscopic mucosal resection of the upper gastrointestinal tract, esophageal ablation procedures, endoscopic ultrasound of the upper GI tract or colonic stenting. The combination of an upper endoscopy and colonoscopy is not a prolonged procedure requiring an anesthesia service.; or
- Documented high risk of intolerance to standard sedatives including but not limited to:
- patient is on chronic narcotics or benzodiazepines, or
- patient has a neuropsychiatric disorder, or
- patient has a history of idiosyncratic reaction to sedatives, or
- patient has a neurodevelopmental impairment; or
- Patients less than 18 years of age; or
- Neurologic, psychological, or developmental disorder necessitating deeper sedation for procedure compliance; or
- Has failed previous endoscopic procedure using moderate (conscious) sedation; or
- Increased risk of complications due to a severe comorbidity (American Society of Anesthesiologists [ASA] class III physical status or greater).
Indications that are not covered
The routine assistance of an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for patients not meeting the above criteria (#3) who are undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered not medically necessary and is not covered.
Monitored anesthesia (deep sedation) and general anesthesia (deep sedation) is not covered for all other indications.
American Society of Anesthesiologists (ASA) Physical Status Classification System:
ASA Physical Status 1: A normal healthy patient
ASA Physical Status 2: A patient with mild systemic disease
ASA Physical Status 3: A patient with severe systemic disease
ASA Physical Status 4: A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5: A moribund patient who is not expected to survive without the operation
Minimal sedation (anxiolysis) is an induced state of altered cognition whereby cognitive function and coordination may be impaired, but airways remain patent (i.e., open/unobstructed) and protective airway reflexes remain intact. The patient is also able to maintain a normal response to verbal commands and physical stimulation. Sedatives that induce minimal sedation include, but are not limited to, benzodiazepines (e.g., diazepam [valium]; lorazepam [ativan]), GABA agonists (zolpidem [Ambien®]; zopiclone [Imovane®] and computer-assisted personalized sedation (SEDASYS®).
Moderate (conscious) sedation is an induced state of sedation characterized by a minimally depressed consciousness such that the patient is able to continuously and independently maintain a patent airway, retain protective reflexes, and remain responsive to verbal commands and physical stimulation. Drugs that induce moderate sedation include, but are not limited to, combination benzodiazepine (e.g., midazolam [Versed®]) and an opioid (e.g., fentanyl) and computer-assisted personalized sedation (SEDASYS®).
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.
Monitored anesthesia (deep sedation) is an induced state of sedation characterized by depressed consciousness such that spontaneous ventilation may be inadequate. The patient is unable to continuously and independently maintain a patent airway and experiences a partial loss of protective reflexes and ability to respond to verbal commands or physical stimulation. Drugs that induce deep sedation include, but are not limited to, propofol (Diprivan®) or dexmedetomidine (Precedex™).
General anesthesia is a drug-induced loss of consciousness whereby patients are not arousable even with painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and ventilation may be required. Cardiovascular function may also be impaired. Drug administration can be either via intravenous injection (IV) or inhalation induction. Commonly used IV agents include etomidate, ketamine, sodium thiopental, and propofol. A commonly-used agent for inhalation induction is sevoflurane.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force: Calderwood, A. H., Chapman, F. J., Cohen, J., Cohen, L. B., Collins, J., Day, L. W., & Early, D. S. (2014). Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointestinal Endoscopy, 79(3), 363-372. http://doi.org/10.1016/j.gie.2013.12.015
- Cohen, J. Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy. In: UpToDate. Saltzman, J. R. & Joshi, G. P. (Eds), UpToDate, Waltham, MA. (Accessed on April 6, 2017.)
- Cohen, J. Overview of procedural sedation for gastrointestinal endoscopy. In: UpToDate, Saltzman, J. R. & Joshi, G. P. (Eds), UpToDate, Waltham, MA. (Accessed on April 6, 2017.)
- Cohen, L. B., Delegge, M. H., Aisenberg, J., Brill, J. V., Inadomi, J. M., Kochman, M. L., & Piorkowski Jr., J. D. (2007). AGA institute review of endoscopic sedation. Gastroenterology, 133, 675–701.
- Standards of Practice Committee: Lichtenstein, D. R., Jagannath, S., Baron, T. H., Anderson, M. A., Banerjee, S., Dominitz, J. A., … Vargo, J. J. (2008). Sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy, 68(5), 815-826. doi:10.1016/j.gie.2008.09.029
- Singh, H., Poluha, W., Cheang, M., Choptain, N., Inegbu, E., Baron, K., Taback, S. P. (2011). Propofol for sedation during colonoscopy. Cochrane Database of Systematic Reviews, 2011(8), 1–63.