The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures when there is documentation by the proceduralist and anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include any of the following:
Increased risk for complications due to severe comorbidity (American Society of Anesthesiologists class III, IV, or V [Table PG1])
Morbid obesity (body mass index >40 kg/m2)
Documented sleep apnea
Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
Spasticity or movement disorder complicating the procedure
History or anticipated intolerance to standard sedatives, such as
Chronic opioid use
Chronic benzodiazepine use
Individuals with active medical problems related to drug or alcohol abuse
Individuals younger than 18 years or 70 years or older
Individuals who are pregnant
Individuals with increased risk for airway obstruction due to anatomic variation, such as:
History of stridor
Dysmorphic facial features
Oral abnormalities (eg, macroglossia)
Neck abnormalities (eg, neck mass)
Jaw abnormalities (eg, micrognathia)
Acutely agitated, uncooperative individuals
Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation (see Policy Guidelines section).
The use of monitored anesthesia care is considered investigational for gastrointestinal endoscopic, bronchoscopic, or interventional pain procedures in individuals at average risk related to use of anesthesia and sedation.
