Triple-S Salud does not routinely recognize separate sedation payment for endoscopic procedures. These services are usually included in the fee as an integral part of the procedure performed by the doctor.
The intervention of the anesthesiologist for the performance of endoscopies is not always considered necessary, in agreement with the related professional organizations.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), uses the recommendations of the Practice Guidelines for Sedation and Analgesia by Non Anesthesiologists issued by American Society of Anesthesiologist. These guides have the endorsement of American Society for Gastrointestinal Endoscopy.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), adopts the guidelines establishing the standard for the credentialing of the personnel involved in the sedation and according to these, the hospital is not required the intervention of the anesthesiologist. However, some people have interpreted the standards of Revision 63: 04/01/2012 JCAHO as a mandatory intervention of the anesthesiologist in this endoscopy procedure.
If the hospital establishes this practice to require the anesthesiologist to perform its service in the endoscopy rooms when there is no exception to the medical policy, Triple-S Salud and/or the member will not be responsible for the payment of these services that don’t meet the criteria’s.
This rule does not apply to patients hospitalized or in the emergency room.
If the patient requires sedation and even general anesthesia for this being medically necessary, the service is covered with prior authorization to the gastroenterologist who will perform the endoscopy service as well as the surgeon who will perform the procedure. Medical necessity must be justified and documented in the patient record. It is necessary that the anesthesiologist in these cases add the pre-authorization number addressed to the gastroenterologist or the surgeon in the box corresponding to these purposes.
Sedation / analgesia would proceed for payment without requiring prior authorization in gastrointestinal endoscopies, bronchoscopies and pain control procedures when they meet the criteria specified and included below. Documentation of medical conditions is required when documenting significant risks that justify this exception. These exception conditions include any of the following:
1. High Risk Patients
a. Pregnant
b. Epilepsy
c. Children 12 years of age or younger
d. Persons 65 years of age or older
2. Danger of Obstruction in the respiratory track
a. History of sleep apnea
b. People with malformations in their facial structure such as people with Pierre-Robin syndrome or Down syndrome (Trisomy 21).
c. People with oral abnormalities such as small opening (less than 3cm in adults); protruding incisors, arch of the upper palate, macroglossia, tonsillar hypertrophy, or an invisible uvula.
d. People with abnormalities in the neck, such as obesity, short neck, limited neck extension, spinal cord instability, «hyoidmental» distance less than 3cm in adults, neck mass, disease or cervical cord trauma. People with anomalies of the facial structures, disorders of the cranial nerves IX or X, tracheal deviation, rheumatoid arthritis.
and.
e. Morbid obesity (BMI greater than 40 or BMI greater than 35 with co-morbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes).
3. People with anticipated intolerance to common sedatives
a. People who have had previous problems with anesthesia or sedation.
b. Dependence of opiates, sedatives or hypnotics.
c. Drug or alcohol abuse.
4. Other
a. People with dementia, psychiatric disorders, small children.
b. Complex procedures or invasive therapeutic procedures, for example: retrograde endoscopic cholangiopancreatography (ERCP), ultrasonic endoscopy (EUS), stenting of the upper gastrointestinal tract, emergency therapeutic procedures.
c. Patients hospitalized or in the Emergency Room.
