Monitored Anesthesia Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for radiofrequency ablation with Coolief technology and monitored anesthesia care (MAC). Sacroiliac joint dysfunction (SIJ) is a very common cause of refractory lower back pain commonly felt in the gluteal region but may also affect the lower extremities and/or the lumbar region. In a study, the authors evaluated radiofrequency ablation (RFA) of the sacroiliac joint (SI) joint and found that all patients who underwent RFA reported excellent pain relief and ceased taking analgesic medications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care for management of the enrollee’s pain during her colonoscopy. Findings: The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the “anesthesia assessment and management of a patient’s actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure.” Also, “While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 48-year-old female who underwent a colonoscopy on 8/1/22 for colon cancer screening. The patient received monitored anesthesia care for the procedure. The 8/1/22 anesthesia report noted the patient had a risk classification score of American Society of Anesthesiologists (ASA) class one and the airway score was graded as a Mallampati 1. There was no documentation of significant cardiac, pulmonary, renal or hepatic disease. There is no documentation by the anesthesia provider that the patient presented with a difficult airway or previous difficulties/ problems with anesthesia. There is no documentation that the patient had issues with substance abuse or was a smoker. The Health Plan has denied this request indicating that the requested treatment was not medically necessary for treatment of the patient.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohn’s disease. The patient reported that there was a questionable perforation episode related to a colonoscopy procedure in 2014. The patient underwent another uncomplicated colonoscopy in June 2017, and the procedural notes did not demonstrate any difficulties with anesthesia or sedation during the procedure. There is no indication that the patient has any cardiac, pulmonary, renal, or liver diseases. There is no evidence of substance abuse. The physical examination was unremarkable, and the patient’s body mass index (BMI) was noted to be 24.77. The provider ordered a repeat colonoscopy to evaluate for active inflammation. The patient has requested authorization and coverage for monitored anesthesia care (MAC).

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 Monitored Anesthesia Care, then check the rights and deadlines that apply to your plan.