Beginning Jan. 1, Blue Cross Blue Shield Massachusetts will no longer cover the use of monitored anesthesia for certain gastrointestinal patients undergoing endoscopic, bronchoscopic, or interventional pain procedures.
It will no longer consider the use of monitored anesthesia "medically necessary" for these procedures unless a patient receives documentation by the operating physician or anesthesiologist/certified registered nurse anesthesiologist that specific risk factors or significant medical conditions are present, according to the new policy published in November.
Patients classified as class I or class II patients, meaning they have no or few comorbidities, according to the American Society of Anesthesiologists' definitions will no longer receive coverage.
"The use of monitored anesthesia care for routine screening and diagnostic colonoscopy in ASA Class I patients is not medically necessary," BCBS claims in the report.
Prior authorization will be required for all monitored anesthesia cases performed in the inpatient setting, and prior authorization may be required in the outpatient setting.
BCBS cited a study from the American Society for Gastrointestinal Endoscopy published 10 years ago as the basis for the change, according to a gastroenterologist who spoke with Becker's.
While this change will just impact patients in Massachusetts, gastroenterologists and industry specialists are concerned about a potential nationwide ripple effect.
"This is not a regional issue. The policy is written in the BCBS national care plan, and if successfully implemented in Massachusetts will surely roll out elsewhere," Max Tilson, MD, a physician with Integrated GI Consultants, told Becker's. "This will obviously have a substantial ripple effect on access, efficiency and acceptance of colonoscopy as the preferred screening tool as anesthesia provided care is used in the majority of outpatient endoscopy centers here."