General Anesthesia for GI Endoscopy MP9519

Covered Service: Yes

Prior Authorization Required: No

Additional An appropriate diagnosis code must appear on the claim. Information: Claims will deny in the absence of an appropriate diagnosis code.

WellFirst Health Medical Policy:

1.0 Use of general anesthesia may be considered medically necessary for upper or lower gastrointestinal endoscopic procedures when there is documentation by the endoscopist or anesthesiology provider that ANY of these specific risk factors or significant medical conditions are present: 1.1 Prolonged or therapeutic endoscopy procedure is planned and requires deep sedation (e.g. endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), upper gastrointestinal stenting, emergency therapeutic procedures; OR

1.2 Anesthesia Risk Category III or greater based on ASA Physical Status Classification System* when there is increased risk for complication because of severe comorbidity; OR 1.3 Morbid obesity (BMI >40, or BMI >35) with comorbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes); OR 1.4 Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment); OR 1.5 Spasticity or movement disorder complicating procedure (e.g. epilepsy, seizure disorder); OR 1.6 Persons with anticipated intolerance of standard sedative (e.g. previous problems with anesthesia or sedation, dependence on opiates, sedatives or hypnotics; or drug or alcohol abuse); OR 1.7 Patients who are pregnant; OR All WellFirst Health products and services are provided by subsidiaries of SSM Health Care Corporation, including, but not limited to, SSM Health Insurance Company and SSM Health Plan. Provider resources and communications are branded as WellFirst Health.

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Coverage of any medical intervention discussed in a WellFirst Health medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 1.8 Acutely agitated uncooperative patients; OR 1.9 Patients with increased risk for airway obstruction due to anatomic variation, such as ANY of the following: 1.9.1 History of sleep apnea or stridor; OR 1.9.2 Dysmorphic facial features (e.g. Pierre-Robin syndrome or Down syndrome); OR 1.9.3 Oral abnormalities (e.g., macroglossia, tonsillar hypertrophy); OR 1.9.4 Neck abnormalities (e.g., neck mass); OR 1.9.5 Jaw abnormalities (e.g., micrognathia, retrognathia or trismus); OR 1.10Patients younger than 18 years or older than 70 years of age. 2.0 Use of general anesthesia care is considered not medically necessary for gastrointestinal endoscopic procedures in patients at average risk related to use of anesthesia and sedation who are undergoing gastrointestinal endoscopic procedures, including endoscopic procedures used in screening.

Appendix:

*American Society of Anesthesiologists (ASA) Physical Status Classification System:

P1: A normal healthy patient P2: A patient with mild systemic disease P3: A patient with severe systemic disease P4: A patient with severe systemic disease that is a constant threat to life P5: A moribund patient who is not expected to survive without the operation P6: A declared brain-dead patient whose organs are being removed for donor purposes.

Committee/Source Date(s) Document Created: Medical Policy Committee/Health Services Division February 20, 2019 Revised: Medical Policy Committee/Health Services Division February 19, 2020 Reviewed: Medical Policy Committee/Health Services Division February 19, 2020 Medical Policy Committee/Health Services Division February 17, 2021

All WellFirst Health products and services are provided by subsidiaries of SSM Health Care Corporation, including, but not limited to, SSM Health Insurance Company and SSM Health Plan. Provider resources and communications are branded as WellFirst Health.

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