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Coming soon! January 1 monitored anesthesia care claim edits
November 1, 2023

This article is for anesthesiologists and gastroenterologists caring for our members

As we’ve previously notified and reminded you, effective January 1, 2024, we will implement diagnosis-driven claim edits to reinforce our existing monitored anesthesia care (MAC) medical policy 154 guidelines.

For our enforcement of this policy on January 1, 2024, it’s important to know that we cover monitored anesthesia care for endoscopic procedures such as colonoscopies and upper endoscopies when medically necessary. Medical policy 154 lists diagnosis codes and clinical scenarios where monitored anesthesia care is medically necessary for endoscopic procedures, outlined by certain medical conditions and complication risks.

Our medical policy aligns with the American Society of Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology, American Gastroenterological Association, and American Society of Anesthesiologists (ASA) guidelines.

Why are we implementing this enforcement?

  • In accordance with the above guidelines, endoscopic procedures can be performed under either moderate sedation or monitored anesthesia care.
  • In appropriately selected patients, moderate sedation is comparably safe and more cost effective than monitored anesthesia care.
  • The member’s cost share is the same for either monitored anesthesia care or moderate sedation, and the amount is based on their plan benefits.
    • Note: If an endoscopic procedure is performed under monitored anesthesia care and does not align with medical policy 154, the member is not liable for the non-covered amount.

As a result of processing claims in accordance with our policy on a pre-payment basis, we are able to reduce the number of claims needing post-payment review.