Monitored Anesthesia Care During Colonoscopy denials in California external review

What the reviewers wrote

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.

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 During Colonoscopy, then check the rights and deadlines that apply to your plan.