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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

September 2016

New Policy: Monitored Anesthesia Care for GI endoscopy

Based on the clinical evidence that most upper and lower endoscopic gastrointestinal (GI) procedures can safely and comfortably be performed with sedation administered by the gastroenterologist, Harvard Pilgrim has developed a new medical policy for monitored anesthesia care (MAC) for upper and lower GI procedures.

Harvard Pilgrim covers MAC for elective upper and lower endoscopy for members with a higher than average risk for sedation-related complications. Effective for dates of service beginning November 16, 2016, Harvard Pilgrim considers MAC for upper or lower gastrointestinal (GI) endoscopy medically necessary for members who meet any of the following conditions:

  • The member is under 18 years old or over 70 years old
  • The member is pregnant
  • There is an increased risk for complications due to severe co-morbidity corresponding to the American Society of Anesthesiologists (ASA) Physical Status Modifier of P3 or greater
  • The patient has an increased risk for airway obstruction due to anatomic variation, such as:
    • History of stridor
    • Dysmorphic facial features
    • Oral abnormalities (e.g. macroglossia)
    • Neck abnormalities (e.g. neck mass)
    • Jaw abnormalities (e.g. micrognathia)
    • The patient has one of the following:
      • History of adverse reaction to sedation
      • History of inadequate response to sedation
      • Obstructive sleep apnea
      • Morbid obesity (e.g. BMI >40)
      • Active or history of alcohol or substance abuse

    Claims for anesthesia services must also be billed with the appropriate Anesthesia Physical Status Modifier:

    P1 — A normal healthy patient
    P2 — A patient with mild systemic disease
    P3 — A patient with severe systemic disease
    P4 — A patient with severe systemic disease that is a constant threat to life
    P5 — A moribund patient who is not expected to survive without the operation
    P6 — A declared brain-dead patient whose organs are being remove for donor purposes

    A prior authorization is not required at this time. Harvard Pilgrim does not cover the use of MAC for GI endoscopy when the conditions listed above are not met. Coverage is guided by recommendations from the American Society of Anesthesiologists and the American Society for Gastrointestinal Endoscopy. For complete information including coding, please refer to Harvard Pilgrim’s Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Medical Policy.

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