Why do you use anesthesia services when my insurance company says that anesthesia is not "medically necessary" for my type of procedure, and it refuses to provide payment for anesthesia? They say I only need moderate sedation.
We are committed to providing you with a safe, comfortable procedure through the use of expert endoscopic technique and personalized and highly effective sedation services. The depth of sedation needed to provide a comfortable procedure varies from patient to patient based on many factors, only some of which are known when a procedure is planned (medical history, gender, body habitus, current medication, previous tolerance for and doses of sedatives used during prior endoscopic procedures). Other factors only become evident during the actual performance of the procedure (degree of sensitivity to colonic manipulation, technical difficulty of the procedure related to unpredictable anatomic factors).
During moderate sedation the patient is conscious and purposely responsive. While conventional moderate sedation afford effective sedation for the majority of routine upper and lower endoscopy cases, in a significant minority if cases it does not. In these instances it may be insufficient to allow comfortable completion of the procedure, necessitating either termination of the procedure or administration of additional medication to achieve a state of deeper sedation (which according to current federal regulations can only be administered in our facility by a CRNA or a second MD who is not performing the procedure).
Deep sedation allows the level of sedation to be safely adjusted to a point of unconsciousness, when desired. Deep sedation is often needed during brief portions of an endoscopic procedure. When a sedation case is begun with preparations for deep sedation (specific staff, medications and monitoring), the doctor is able to adjust the depth of sedation continuously through the procedure, using light-moderate sedation when that is all that is needed, but rapidly increasing sedation from moderate to deep for periods during which a greater depth of sedation is necessary to maintain comfort.
We have used deep sedation safely and effectively for over 8 years at the Southwest Endoscopy Center, where our experience using it exceeds 24,000 cases. In 2006 our practice joined with other facilities around the world offering cost-effective "endoscopist-directed propofol" (EDP) sedation services. In December 2009 the federal government, in a controversial action leading to continued contentious debate in our specialty, classified deep sedation to be "anesthesia" and required that it be administered only by an anesthesia provider when it is used in Medicare-certified facilities such as hospitals and ambulatory surgery centers. In order to continue providing our patients with the high quality level of sedation we had historically used in a safe and effective manner we added a certified nurse anesthetist (CRNA) to our sedation team. This addition incurs additional professional costs for which our anesthetist submits a bill. In our facility, anesthesia services are provided by Animas Anesthesia Associates, LLC.
Insurance companies have varying policies regarding coverage for deep sedation. Some companies choose to cover only moderate sedation (also called conscious sedation). We believe that this position is outdated and fails to recognize both significant improvements in the safety and effectiveness of sedation practices and the regulatory constraints under which Medicare-certified facilities must operate. The U.S. Food and Drug Administration (FDA) has published the following statement regarding the depth of sedation induced for colonoscopy:
"For endoscopic procedures, particularly colonoscopies, a light-to-moderate level of sedation is needed for less stimulating parts of the procedure. However, the anesthetic requirements often increase substantially during the more painful portions of the procedure (for example, when negotiating the colonoscope through the splenic and hepatic flexures). Hence, a state of deep sedation is likely to be induced during the more painful parts of the procedure to manage pain and minimize patient movement and the concomitant risk of bowel perforation." (emphasis added)
-August 11, 2010 - Statement of the FDA in FDA-2005-P-0059
The Centers for Medicare & Medicaid Services, in its July 2014 proposed 2015 Physician Fee Schedule cited a changing standard care with respect to the use of anesthesia services for screening colonoscopy, noting that in 2013, anesthesia services were utilized in 53% of U.S. screening colonoscopies in Medicare patients.You may choose to decline deep sedation and schedule your procedure either without sedation or with only moderate sedation if your doctor agrees to attempt your procedure under these conditions. If you choose to limit your sedation to the moderate level you must accept the limitations of moderate sedation as discussed on our Sedation Options page. Please review the moderate sedation consent form for your procedure on our Forms page.
On November 9, 2010 we received the following communication from Anthem Blue Cross and Blue Shield of Colorado:
As of Nov. 1, 2010, coverage decisions will reflect a changing local standard of care. As a result, if a GI endoscopic procedure is otherwise covered, Anthem will also provide coverage for anesthesia services during lower GI endoscopic procedures such as colonoscopy (CPT 00810) and upper GI endoscopic procedures (CPT 00740)
Links to additional anesthesia resources and Anthem clinical guidelines
I had a procedure in the past with Versed (midazolam) and fentanyl. It seemed fine. Can I just have this same sedation again?
While upper endoscopy and colonoscopy can be performed successfully in a very high percentage of patients with traditional sedation methods using opioids-benzodiazepines (such as midazolam and fentanyl), which we used routinely at our facility until converting to propofol-based sedation in 2006, the intended level of sedation needed to achieve success (defined as that needed for patient tolerance of the procedure) often exceeds a level of moderate sedation (extending into deep sedation). Federal regulations now specifically preclude the use of these drugs in this manner by individuals who are not qualified as anesthesia providers by statute. Your doctor will consider this form of sedation only if he or she believes that it will be adequate based on review of your prior procedure records, including the doses of medications administered, to ensure that they conformed with the FDA-approved labeling for these agents.
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