UPDATE ON COLONOSCOPY SEDATION COVERAGE
On January 1, we began enforcing a longstanding policy intended to ensure that our members get the appropriate care when they undergo important gastrointestinal screening procedures such as colonoscopies.
Since then, it’s become clear to us that there is confusion about the policy and the reasons for it. The confusion stems from inaccurate information about our coverage for the different types of sedation available to members for these procedures.
The purpose of our action was to ensure that our members receive the type of sedation most clinically appropriate for them and consistent with national medical guidelines.
Given the confusion, we’ve decided to pause enforcement of this policy while we work to make sure our members understand all their options for colon cancer screening and sedation and that they feel confident they’re getting the care that’s best for them.
Colorectal cancer is the second leading cause of cancer deaths in the United States, but screening reduces the risk of dying from this form of cancer. We encourage our members to talk to their primary care doctor about all their screening options, including at-home tests and colonoscopy, and what type of sedation may be best for them.
Types of Sedation for Colonoscopies and Upper Gastroenterology (GI) Endoscopies
There are two different types of sedation that are commonly used with these procedures:
- Deep sedation (also referred to as monitored anesthesia care or MAC) typically uses a drug called propofol. With this medication, you cannot be easily woken up, cannot respond to verbal commands, and may require intubation. Medical evidence suggests propofol should be limited to patients with specific risk factors or medical conditions. With deep sedation, patients cannot drive after the procedure and must have an escort to take them home.
- Moderate sedation is a level of sedation where a patient receives enough medication to feel very relaxed or sleepy, but can still respond to verbal commands. Patients typically don’t remember the procedure. Even with moderate sedation, patients cannot drive after the procedure and must have an escort to take them home.
Frequently Asked Questions
No. There is no change to our existing medical policy 154. We are again sharing and reinforcing our current policy – which is based on guidelines published by the American Society for Gastrointestinal Endoscopy - and asking providers to follow specific billing procedures.
This is not accurate. Your benefits for sedation with colonoscopy have not changed. Any member with a clinical need for deep sedation (sometimes known as monitored anesthesia) will still be able to get it at no additional cost.
You do not need to do anything. You can receive deep sedation when your doctor determines it’s most appropriate for you.
Deep sedation is covered for Medicare Advantage members who are aged 70 and older. For Medicare Advantage members younger than 70, deep sedation is covered when specific risk factors or significant medical conditions are present or when there is a clinical need as identified by their doctor. Examples of covered diagnoses include, hypertension, diabetes, dementia, heart condition.
No. Deep sedation is covered for all members younger than 18.