Monitored Anesthesia Care During Colonoscopy denials: what the review data shows
Independent reviewers have decided 20 published cases where an insurer denied Monitored Anesthesia Care During Colonoscopy — and they overturned the insurer 5% of the time. A denial for Monitored Anesthesia Care During Colonoscopy is a starting position, not a final answer.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monitored anesthesia care (MAC) services during colonoscopy. According to the American Society of Anesthesiologists (ASA) guidelines, for patients who may require only minimal sedation, MAC is often indicated as even small doses of these medications could precipitate adverse physiologic responses that would require acute clinical interventions and resuscitation. The ASA guidelines note that the attention of the proceduralist should be focused on the completion of the procedure, not physiologic alterations. According to one medical study, patients with bowel obstruction are considered high aspiration risk patients, and the decision to perform the procedure under MAC versus a more secure airway such as an endotracheal tube should be left to an anesthesiologist.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) provided during a colonoscopy. 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 ASA Class I, II, or III.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) during the colonoscopy procedure at Santa Maria Digestive Diagnostic Center. 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 ASA Class I, II, or III.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Monitored Anesthesia Care During Colonoscopywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY