January 11, 2009

Aetna has announced that it will stop paying for anesthesia services for upper and lower GI endoscopies in healthy patients effective April 1, 2008. Many ABC clients and other anesthesiologists received personal telephone calls from Aetna representatives in December, presaging official letters that went out shortly after New Year. The policy itself has not yet been made public. Aetna is basing this decision in large part on the 2004 joint statement in which the three leading GI societies took the position, "The routine assistance of an anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted."In the face of the gastroenterology associations" statement, significant geographical variation in the use of anesthesia services for routine screening endoscopies and divided opinion among its membership as to the medical necessity for anesthesia for routine endoscopic procedures, ASA did not mount a frontal assault when Aetna and other payers began to adopt restrictive policies in 2006. ABC believes that it will be very difficult, therefore, to persuade Aetna to reverse itself and continue to pay for monitored anesthesia care (MAC) for all endoscopies after April 1st. We note, however, that the New York State Society of Anesthesiologists, which has a position similar to ASA's, is considering options together with the New York GI leadership. We encourage our New York clients to monitor NYSSA announcements closely. We also encourage clients in the New York area and elsewhere who believe that Aetna's policy depends on too narrow a definition of "medical necessity" to write to James D. Cross. M.D. Head of Medical Policy and Program Administration, AETNA, 151 Farmington Avenue; Hartford, CT 06156 as well as to the Insurance Commissioner for your state—and even your local newspapers. Under the current AMA definition of "medical necessity,"anesthesiologists arguably could still be using ether because newer anesthetics were not all "Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:

1. in accordance with generally accepted standards of medical practice;
2. clinically appropriate in terms of type, frequency, extent, site, and duration; and
3. not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider."

Realistically, though, there is a strong likelihood that the new Aetna policy will go into effect on schedule, and we are preparing to assist our clients with the following actions:

1. Gain a clear understanding of the endoscopy patients for whom Aetna will continue to cover what it calls "deep sedation" provided by an anesthesiologist or nurse anesthetist. In its December 2007 "Dear Doctor" letter, Aetna wrote that the list of eligible patients includes those 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

We anticipate that these patient conditions will be identified, in future claims, by specific ICD-9 codes.

2. Work with you to help you select the appropriate ICD-9 codes and systematically include those ICD-9 codes on your claim submissions.
3. Help you with standardized documentation of additional explanations of medical necessity.

• Implement Aetna's instruction to let the patient know that conscious sedation will be covered, but if the patient chooses "deep sedation" in the absence of specific risk factors, Aetna most likely will not pay for the service and the patient will be personally liable for the anesthesia bill.
• By attaching the "advance beneficiary notice" (ABN) form to its Dear Doctor letter, Aetna obviously intended to make these notices standard practice and to help you deal with patients', endoscopy centers' and/or colleagues' objections to seeking payment from the patient.
• Many of you already have in place procedures to help patients decide whether to pay for anesthesia for endoscopies out of pocket. It might be possible, for example, to enlist the GI practice in explaining that Aetna will only pay for conscious sedation and having the patients contact you if they have concerns about foregoing anesthesia or the ABN that they receive from the GI office.
• Run reports showing the financial impact to your practice of the change in Aetna's policy.

Please be sure to share any further letters or other communications from Aetna with information on the new endoscopy policy with your ABC Account Manager. We will do likewise, and will do our utmost to help you in meeting this challenge.