201908-120457
2019
Oscar Insurance Company
EPO
Digestive System/ Gastrointestinal
Anesthesia
Medical necessity
Upheld
Case Summary
Diagnosis: Colonoscopy
Issue under review: Anesthesia
Determination:
The Anesthesia was not medically necessary.
Patients may undergo GI (gastrointestinal) endoscopic procedures without sedation, analgesia, or both. The majority of patients however receive some level of sedation and analgesia to relieve patient anxiety and discomfort and improve the outcome of the examination.
The level of sedation and analgesia required to perform endoscopic procedures varies. Patient age, health status, concurrent medications, pre-procedural anxiety and expectation, as well as pain tolerance influence the level of sedation required to achieve the desired result, as do procedural variables such as the degree of invasiveness and the duration of the procedure. Patients like this patient are generally informed of and agree to the administration of sedation and analgesia with endoscopic procedures, including a discussion of the benefits, risks, limitations, and possible alternatives. By definition: "Monitored anesthesia care may include varying levels of sedation, analgesia and anxiolysis as necessary. Monitored anesthesia care is a physician service provided to an individual patient." (1)
Many factors may contribute to the decision to have anesthesiologist-directed sedation for endoscopic procedures. "MAC is indicated for some patients based on the nature of the procedure they are to undergo, their medical condition, or the potential need to covert to general anesthesia during the procedure. MAC differs from moderate sedation in that it is provided by an anesthesiologist or certified registered nurse anesthetist who makes an assessment in advance of the actual or potential medical problems that may occur during the procedure." (2)
There are theoretical advantages with MAC, versus benzodiazepines and narcotics, for patients with risk factors for sedation-related complications and for patients undergoing prolonged procedures. However, MAC carries substantial risk. With MAC, Wernli et al. did not demonstrate any increased cardiopulmonary risks such as hypotension or myocardial infarction, but did suggest an increase in stroke occurrence, as well as an increase in endoscopic perforation and hemorrhage. This study used 30-day administrative claims data to study complications. A study of similar design using the SEER database further identified aspiration as a risk factor associated with propofol anesthesia.
Available records, however, in this patient's case do not support that the risk factors warranting MAC were present, nor were the risk factors associated with MAC justifiable - In the patient's case, for example: anticipated prolonged procedure time, advanced ASA classification, dysmorphia, history of or anticipated trouble with conscious sedatives. As such, the patient's request for Plan coverage of MAC, based on available records, fails to meet the community-accepted indications for MAC and the conventional definition of "medical necessity."
Denial of service is upheld given the lack of provided documentation that in the patient's case, MAC was necessary in lieu of conscious sedation.