Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that in keeping with the American Society of Anesthesiologists' standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.  -  During MAC, the patient's oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.  -  Please see CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 50 and 140.3 for CMS requirements for this type of anesthesia.  -  Anesthesia procedures listed in the "CPT/HCPCS Codes" section of the related Local Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361), are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, MAC provided by anesthesia personnel may be reasonable and necessary for procedures that are generally provided by the attending surgeon if certain conditions or situations are present. In these situations, MAC may be necessary for these active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. Refer to the related billing and coding article for diagnoses that support the use of MAC in these situations. Special conditions or criteria must be supported by documentation in the medical record.  -  The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.  -  For procedures that do not usually require anesthesia services, MAC could be covered when the patient's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient's medical record.  -  The presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.  You can find this rule at Local Coverage Determination (LCD) L35049: Monitored Anesthesia Care (eff. 10/17/19).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.