Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohns disease. The patient reported that there was a questionable perforation episode related to a colonoscopy procedure in 2014. The patient underwent another uncomplicated colonoscopy in June 2017, and the procedural notes did not demonstrate any difficulties with anesthesia or sedation during the procedure. There is no indication that the patient has any cardiac, pulmonary, renal, or liver diseases. There is no evidence of substance abuse. The physical examination was unremarkable, and the patients body mass index (BMI) was noted to be 24.77. The provider ordered a repeat colonoscopy to evaluate for active inflammation. The patient has requested authorization and coverage for monitored anesthesia care (MAC). The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether MAC is medically necessary for the treatment of the patients medical condition. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice committee concluded that, We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The ASGE also noted, We recommend anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The ASGE reported, `Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. Wernli and colleagues concluded that, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. The patient did not have any documented heart, lung, kidney, or liver diseases. There was no documentation of alcohol or substance abuse. There was no indication the patient had any difficulty with anesthesia or sedation in previous colonoscopies. The patient has a BMI of 24.77, which does not indicate obesity. There is no indication the patient has a difficult airway to manage. The medical evidence does not support the requested service in this clinical setting. Therefore, MAC is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.