Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 52-year-old female who underwent a screening colonoscopy on 5/5/22. The 
patient has requested reimbursement for anesthesia for lower intestinal endoscopic procedure 
on 5/5/22. The Health Insurer has denied this request and reported the service at issue was not 
medically necessary for the treatment of this patient. The physician reviewer found that the 
submitted documentation does not support the medical necessity of the service at issue. The 
American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted 
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 authors recommended that, 
anesthesia provideradministered sedation be considered for complex endoscopic procedures 
or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines 
also noted, 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. Vargo and colleagues 
concluded, Use of anesthesia professionals does not appear to bring a safety benefit to patients 
receiving colonoscopy and is associated with an increased serious adverse events risk for ASA I, 
II, and III patients undergoing esophagogastroduodenoscopy. Wernli and colleagues reported 
that the 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 authors 
further noted that for most outcomes, there were no differences in risk with anesthesia services 
by polypectomy status, however, the risk of perforation associated with anesthesia services was 
increased only in patients with a polypectomy. In this case, the patient presented for and 
underwent a routine colonoscopy. She did not have any significant heart, lung, kidney, or liver 
disease. There was no documentation of a history of alcohol or substance abuse. There was no 
detailed description of a previous history of difficulties with anesthesia or sedation with past 
colonoscopies documented in the submitted records. The records did not note an ASA risk 
classification score or a Mallampati airway grade. The literature does not support the use of 
monitored anesthesia care in a patient who does not have significant health conditions or airway 
concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild 
to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. 
Based on  the current medical evidence, the service at issue was not  medically indicated.  
Therefore, anesthesia for lower intestinal endoscopic procedure on 5/5/22 was not medically 
necessary for the treatment of this patient.