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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with gastroesophageal reflux disease (GERD)/dysphagia. The patients body mass index (BMI) was 25 kg/m2.  The patient underwent a colonoscopy with propofol as anesthesia. His airway was graded with a Mallampati score of one. The patients American Society of Anesthesiologists (ASA) score was one, and there was no documentation of a potentially difficult airway. There is no documentation the patient had previous difficulties or problems with anesthesia. There is no record of any cardiac, pulmonary, renal or hepatic comorbidities. The patient was not on any outpatient medications and did not have any known drug allergies. There is no documentation that the patient had issues with substance abuse or was a smoker. The patient has requested reimbursement for anesthesia CPT-00812 (34 units) for his colonoscopy. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether anesthesia CPT-00812 (34 units) for the patients colonoscopy was 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 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. In this case, 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 difficulty with anesthesia or sedation. The patient was given an ASA classification score of one and had a Mallampati airway grade of one. The medical evidence does not support the services at issue in this clinical setting. Therefore, anesthesia CPT-00812 (34 units) for his colonoscopy was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.