00810
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Monitored Anesthesia Care (for definition, see Discussion below)
- Monitored anesthesia care is consideredmedically necessaryduring gastrointestinal endoscopic procedures when there is documentation by the operating physician or the anesthesiologist that demonstratesanyof the following higher risk situations exist:
- Prolonged or therapeutic endoscopic procedure requiring deep sedation such as endoscopic retrograde cholangiopancreatography (ERCP) or repeat colonoscopy due to tortuous colon;or
- A history of or anticipated poor response due to cross tolerance or paradoxical reaction to standard sedatives used during moderate (conscious) sedation specifically due to narcotics or benzodiazepines;or
- Increased risk for complication due to severe comorbidity (American Society of Anesthesiologists [ASA] class III physical status or greater. See Appendix for physical status classifications);or
- Individuals over 70;or
1 Active Policy
ANTHEM-CG-MED-34 — CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.