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IMPORTANT INFORMATION

 

                                                                                                December, 2007

Dear Physician and/or Practice Manager:

We’re implementing a new clinical policy for monitored anesthesia care
(MAC) for GI endoscopy

Effective April 1, 2008, we will implement a new clinical policy for anesthesia services for upper and lower gastrointestinal (GI) endoscopy. A summary of the coverage guidelines is provided below.

Please review the policy and, where applicable, inform your patients as described later in this letter. The policy will be posted on our public website, www.aetna.com, once it becomes effective.

MAC will only be covered under certain circumstances

Under this policy, we will no longer routinely cover MAC for patients with no sedation-related risk factors who are undergoing GI endoscopy. We will, however, continue to cover conscious sedation (as part of the GI endoscopy) for patients with no sedation-related risk factors.

For patients who have sedation-related risk factors, we will continue to cover MAC, which requires the attendance of an anesthesiologist or anesthetist. This includes patients who are:

Pregnant

18 years of age or younger

65 years of age or older

At increased risk for complications due to certain classes of physical status according to the American Society of Anesthesiologists

In danger of airway compromise, including those with oral, neck or jaw abnormalities; sleep apnea; or those who are morbidly obese

Uncooperative or combative

Dependent on opiates or sedatives

Scheduled for certain complex or prolonged GI endoscopic procedures

Diagnosed with epilepsy

Identified as having a history of drug or alcohol abuse, or previous problems
with sedation or with an endoscopic procedure

Conscious sedation is safe and frequently used

Conscious sedation is a safe and well-tolerated choice for most patients undergoing GI endoscopy. There is no generally accepted evidence demonstrating that average-risk patients require MAC for routine GI endoscopy. Therefore, we will cover MAC only for patients undergoing GI endoscopy with sedation-related risk factors, as listed above. 

Our clinical policy is consistent with the positions of professional organizations

Our clinical policy is consistent with the following statement on sedation for performing GI endoscopic procedures. The statement was issued jointly in 2004
by the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy.

 

“The routine assistance of an anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is
not warranted.”

We have also reviewed our policy throughout its development with the American Society of Anesthesiologists.

Before routine GI endoscopy is performed with planned MAC, let the patient know that MAC will likely not be covered

We do not expect any patient to have a GI endoscopy without sedation. However, if a patient at average risk requests MAC, you should tell him/her before the procedure that the service(s) of an anesthesiologist or anesthetist will likely not be covered under the terms of his/her benefits plan. Also, let the patient know he/she may be responsible for payment of any anesthesia services that are not covered.  Informing the patient of his/her financial responsibility in these circumstances is consistent with the obligations set forth in your participation agreement with Aetna.

Enclosed is a sample acknowledgement form that a patient may sign before a
GI endoscopy to acknowledge his/her understanding. If the patient is informed before the procedure that anesthesia services may not be covered and that he/she may be financially responsible, the provider may bill the patient for these services following receipt of a coverage determination from Aetna. Please keep a copy of
this acknowledgement in your files. Please note that even if a member signs an acknowledgement form, he/she still has the right to appeal our determination to deny coverage and that the provider is expected to cooperation in any such appeal.

Preventive care screenings are recommended

We strongly advocate preventive care, including recommended cancer screenings like colonoscopy. We cover screening colonoscopies in all plans that include preventative care benefits.

Contact us if you have questions

You can call our Provider Service Center at 1-800-624-0756 for questions related to HMO-based benefits plans or 1-888-632-3862 for questions related to indemnity and PPO-based benefits plans. Or, you can contact your Aetna network representative.

 

Sincerely,

James D. Cross, M.D.
Head of Medical Policy and Program Administration

 

V
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Patient Acknowledgement Monitored Anesthesia Care (MAC)

I understand and acknowledge that:

I have been offered conscious sedation for a gastrointestinal endoscopy
by my medical provider.

I have requested MAC for my gastrointestinal endoscopy.

MAC will likely not be covered under the terms of my Aetna benefits plan.

If this service is not covered, I have been provided with information concerning the costs of MAC, for which I may be responsible.

 

Name

___________________________________________________________



Date

___________________________________________________________



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RC McLean & Associates, Inc.

210 North Tustin Avenue
Santa Ana, CA 92705-3807

P.O. Box 25033
Santa Ana, CA 92799-5033

(714) 347-1000 : local
(800) 883-7243 : toll free
(714) 647-1250 : fax

garyc@rcmclean.com
http://www.rcmclean.net


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