In November, Blue Cross Blue Shield Massachusetts announced that beginning Jan. 1, it would no longer cover the use of monitored anesthesia for certain gastrointestinal patients undergoing endoscopic, bronchoscopic or interventional pain procedures.
Now that the policy has officially gone into effect, monitored anesthesia is no longer considered "medically necessary" for these procedures by the insurer, unless a patient receives documentation by the operating physician or anesthesiologist/certified registered nurse anesthetist that specific risk factors or significant medical conditions are present.
Patients with few or no comorbidities will no longer receive coverage. 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 the policy has only been in effect for a little over a week, some physicians are wary of its impact on patient care.
"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," Max Tilson, MD, a physician with Chelmsford, Mass.-based Integrated GI Consultants, told Becker's.
"We're concerned about this implementation because it will probably reduce access to screening procedures. One, with the ongoing nursing shortage and this not being the standard of care currently, we'll have to find staff to implement what they're looking for and two, more importantly, patient comfort and concerns may prevent patients from coming in for their procedures whereas they weren't as reluctant in the past," Lauren Bleich, MD, a gastroenterologist at Gastro Health in Acton, Mass., told Becker's.
"Our intention with all our medical policies is that our members have access to high quality, safe, effective and affordable care. This long standing policy has always been grounded in GI specialty society recommendations and clinical guidelines. Moderate sedation is an established, safe, effective alternative to propofol that is always covered when deep sedation is not required," Sandhya Rao, MD, chief medical officer at BCBSMA, told Becker's. "Propofol remains available for qualifying patients and is one of many sedation options that doctors select to perform these procedures safely and effectively. Over the past year, we've met with providers and representatives from professional societies to hear their concerns. We used their feedback to expand the list of conditions for which deep sedation will be deemed clinically necessary. Any Blue Cross member who clinically needs this form of deep sedation will get it. Examples include (but are not limited to) patients with conditions that warrant a more regular cadence for colonoscopies (annually), patients who have a failed procedure, patients who have a fear of medical procedures and patients who have a chronic condition (e.g., diabetes, high blood pressure, Crohn's) that warrants the use of deep sedation."