Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia care.

You asked the Plan to pre-approve monitored anesthesia care. You say that the requested monitored anesthesia care for the approved colonoscopy is medically necessary. The Plan denied your request. The Plan says the requested monitored anesthesia care for the approved colonoscopy is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve monitored anesthesia care. Our reviewer says that the requested monitored anesthesia care for the approved colonoscopy is not medically necessary. Our physician reviewer found the enrollee is with a history of osteoporosis, anemia, atrophic vaginitis, constipation, depression, Dupuytren contracture, Gastroesophageal Reflux Disease (GERD), hyperlipidemia, hypertension, nummular eczema, vertigo, and vitiligo. Her body mass index is 20.63 kg/m2 and her cognitive function is within normal limits. The enrollee is scheduled for a screening colonoscopy. 

According to the American Society of Anesthesiologists (ASA), a monitored anesthesia care (MAC) is a planned procedure during which the patient undergoes local anesthesia together with sedation and analgesia.

MAC may include varying levels of sedation, analgesia, and anxiolysis, including but not limited to moderate sedation. Some factors or significant medical conditions may include ANY of the following: Patients with potential for difficult intubation and/or ventilation with a mask, or at risk for airway obstruction; Increased risk for complication due to severe co-morbidity: ASA Class III physical status or greater (Class III ASA is defined as severe systemic disease that limits activity, but is not incapacitating, e.g., stable angina, history of myocardial infarction, history of stroke, insulin dependent diabetes, poorly controlled disorders, e.g., hypertension, asthma, psychiatric disorders, dysrhythmias, congestive heart failure, chronic obstructive pulmonary disease; patients with chronic degenerative neurologic diseases which may cause difficulty swallowing or pose a risk for muscle weakness and respiratory failure; Morbid obesity (BMI greater than 50); or Extremes of age, i.e., greater than 70 years of age or less than 18. 

The review has determined that this enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of MAC. There is no documentation in the enrollee's record indicating that it is medically necessary to have an anesthesiologist present during this colonoscopy. It is not medically necessary and reasonable for this enrollee to have MAC, as requested. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of monitored anesthesia care have not been met. Therefore, we decided that the Plan does not have to pre-approve monitored anesthesia care.