151 Farmington Avenue
Hartford, CT 06156
October 15, 2006
Dear Physician or Practice Manager
We developed a new clinical policy for anesthesia services for GI endoscopy. A few months ago, we notified you that we were reviewing clinical information relating to the appropriateness of anesthesia services for upper or lower gastrointestinal endoscopic procedures.
Effective February 1, 2007, we will be implementing a new clinical policy regarding anesthesia services for GI endoscopy. A summary of coverage guidelines is provided below, and the complete Clinical Policy Bulletin (CPB) will be available through www.aetna.com by the effective date.
Anesthesia services for GI endoscopy are considered medically necessary under certain circumstances
As stated in our CPB, we will consider anesthesia and the attendance of an anesthesiologist or anesthetist to be medically necessary for upper or lower GI endoscopic procedures for patients with sedation-related risk factors. These include patients who are:
- 18 years of age or younger
- 65 years of age or older
- At increased risk for complication due to severe co-morbidity according to the ASA Physical Status Class P3 to P5
- In danger of airway compromise, including those with oral, neck or jaw abnormalities; sleep or those who are morbidly obese
- Uncooperative or combative
- Dependent on opiates or sedatives
- Scheduled for certain complex or prolonged procedures
Anesthesia services are also appropriate for patients with history of drug or alcohol abuse or a history of previous problems with sedation.
The CPB is consistent with the following statement on sedation for performing endoscopic procedures that was issued jointly on March 8, 2004, by the American College of Gastroenterology, American Gastroenterology Association and American Society for Gastrointestinal Endoscopy: “The routine assistance of anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted.” We also reviewed related coding recommended by the American Society of Anesthesiologists to help ensure proper administration of this policy.
Aetna is the Brand name used for products and services provided by one or more of the Aetna group subsidiary companies. The Aetna companies that offer, underwrite or administer benefits coverage include Aetna Health Inc, Aetna Health of California Inc, Aetna Health of the Carolinas Aetna Health Insurance Company of Connecticut, Aetna Health of Illinois Inc, Aetna Life Insurance Company, Aetna Health Insurance Company of New York, Corporate Health Insurance Company, Aetna Health Management Inc, and Aetna Health Administrators , LLC.
Claims for anesthesia services in other circumstances will be denied. Please note that claims for anesthesia services for patients not meeting the above criteria will be denied. If you desire to provide anesthesia services for other patients, you should inform them before providing the service that physicians may bill them separately for the anesthesia services that are not covered.
Contact us if you have questions
Thank you for your continued participation in the Aetna network. You can reach a Provider Service Center representative at 1-800-624-0756 for calls related to HMO-based benefits plans or 1-888-MD-AETNA (1-888-632-3862) for calls related to indemnity and PPO-based benefits plans.
James D. Cross, M.D.
Head Of medical Policy Administration