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anesthesia services management

July 16, 2007

Dear Physician or Administrator:

The purpose of this letter is to update you on Humana's policy regarding the assistance of an anesthesiologists or certified registered nurse anesthesiologists (CRNA) during an adult gastrointestinal endoscopic procedure. Effective 90 days from the date of this letter. Claims that do not meet the criteria outlined within this letter may be subject to medical review and may not be covered. This letter/policy applies to all lines of business and all products, except Humana's Medicare Advantage (MA) Private Fee-for-Service (PFFS) plans.

Humana's policy is that the standard assistance of anesthesiologist or a CRNA for average risk patients (ages 18 and older) undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered not medically necessary.

This policy is consistent with a joint statement published by the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy in 2004. In general, diagnostic and uncomplicated therapeutic endoscopies and colonoscopies can be successfully performed with moderate (conscious) sedation.

Therefore, please note that all claims,, except MA PFFS claims, for current Procedure Terminology (CPT) codes 00740 and 00810 – anesthesia for endoscopic procedures – will be subject to medical review for compliance with this policy effective 90 days from the date of this letter.

Per Humana’s medical policy, anesthesia services may be considered medically necessary during gastrointestinal endoscopic procedures in any of the following situations:

  • Prolonged or therapeutic endoscopic procedures requiring deep sedation:
  • Anticipated intolerance to standard sedatives:
  • Increased risk for airway obstruction due to anatomic variant:
  • Increased risk for complication due to serve comorbidity (American Society of Anesthesiologists | ASA | Class III physical status classification or greater*)

*ASA Physical Status Classification System
P1 - A normal healthy patient
P2 - A patient with mild systemic disease
P3 - A patient with serve systemic disease
P4 - A patient with mild systemic disease that is constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 - A declared brain-dead patient whose organs are being removed for donor purposes

To view Humana’s complete policy document on this topic. Visit the anesthesiologists-Assisted Sedation for Endoscopes site (http://apps.humana.com/md/md_new/issuedetail.asp?issue=779) on the web.

We hope you find this information helpful. If you have any questions. Please contact Humana Customer Service at the number listed on the back of the member’s Humana’s ID card. Or please call 1-800-4HUMANA (1-800-448-6262)

Thank you for your care of our members. Sincerely Steven E. Goldberg. M.D., M.B.A. Corporate Medical Director, Clinical Policy Human

anesthesia

 


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