Anesthesia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia (CPT code 00731) administered during the endoscopy procedure received. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether anesthesia (CPT code 00731) administered during the endoscopy was medically necessary for the treatment of the patient’s medication condition.

A 46-year-old female enrollee has requested anesthesia services provided during an endoscopy for treatment of her history of allergy/intolerance to multiple medications. Findings: The physician reviewer found that based on review of the available records, anesthesia services were medically necessary for the patient’s endoscopy performed on said date. The enrollee presented with a history significant for sleep apnea, a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep. Sleep apnea is particularly accentuated during medication-induced sedation. Anesthesia services are highly recommended for sleep apnea due to risk of airway obstruction. Hausman and Reich stated that not all procedures are well suited for the office with sedation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia service. Findings: The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the “combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events.” The authors recommended that, “Anesthesia provider–administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise.” The guidelines also noted, “Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services administered during the colonoscopy. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that that use of a “combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events” (Early, et al.). The guidelines further state that, “Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Anesthesia, then check the rights and deadlines that apply to your plan.