Use of Anesthesia Services for Routine Gastrointestinal Endoscopy
Policy:
The use of anesthesia services to provide sedation and analgesia for patients for routine
gastrointestinal endoscopy procedures does not meet Blue Cross and Blue Shield of Alabama’s
medical criteria for coverage except for the following:
• Patients with potential for difficult intubation and/or ventilation with a mask, or at risk for airway obstruction, including but not limited to:
o Patients with previous problems with anesthesia or sedation;
o Patients with a history of stridor or tracheal stenosis
o Patients with a diagnosis of clinically significant sleep apnea;
o Morbidly obese patients;
o Patients with dysmorphic facial features, such as Pierre-Robin syndrome, or trisomy-21, or Turner’s syndrome;
o Patients with oral abnormalities, such as a small opening (<3 cm in an adult),
macroglossia, tonsillar hypertrophy, or a nonvisible uvula;
o Patients with neck abnormalities, such as limited neck extension, decreased hyoid mental distance (<3 cm in an adult), neck mass, oral or glottic tumors, previous head and neck surgery or radiation, unstable cervical spine, tracheal deviation due to mass or previous surgery, ankylosed cervical spine or advanced rheumatoid arthritis;
o Patients with IX or X cranial nerve impairment;
o Patients with spinal cord instability;
o Patients with jaw abnormalities such as micrognathia, retrognathia, trismus, or
significant malocclusion.
• Patients with allergies to sedation and analgesia agents;
• Alcohol or drug addicted patients or patients with increased tolerance to sedation and
analgesic agents such as patients with a chronic pain syndrome;
• Patients with increased risk for aspiration, e.g., diabetics with autonomic neuropathy and
gastroparesis, achalasia, ascites, swallowing disorders, or bulbar neurologic disorders;
• Patients with chronic degenerative neurologic diseases which may cause difficulty
swallowing or pose a risk for muscle weakness and respiratory failure e.g., multiple
sclerosis, myasthenia gravis, Parkinson’s disease, ALS, etc.;
• Extremes of age, i.e., < 1 year of age or > 70 years of age;
• Combative or uncooperative patients;
• Patients with neurobehavioral delays when rapid onset of sedation is a safety concern;
• Uncooperative pediatric patients;
• Patients with history of severe, nausea and/or vomiting after administration of sedation
with narcotics and/or benzodiazepines;
• Patients undergoing prolonged or complex diagnostic or therapeutic procedures such as
ERCP;
• Class III ASA patients when respiratory and/or cardiac complications are a concern.
Class III ASA is defined as severe systemic disease that limits activity, but is not incapacitating, e.g., stable angina, H/O myocardial infarction, H/O stroke, insulin dependent diabetes, poorly controlled disorders, e.g., HTN, asthma, psychiatric disorders, etc., dysrhythmias ,CHF, COPD
• Class IV ASA patients (severe systemic disease that limits activity and is a constant
threat to life), e.g.,
o Myocardial infarction within last 6 months
o Stroke within last 6 months
o Unstable angina
o Severe CHF
o Severe COPD
o Hepatic failure
o Renal failure
o Uncontrolled epilepsy
The purpose of Blue Cross and Blue Shield of Alabama’s medical policy is to provide a guide to
coverage. Medical policy is not intended to dictate to physicians how to practice medicine.
Physicians should exercise their medical judgment in providing the care they feel is most
appropriate for their patients.
