CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures

This document addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures. This document does not address whether or not reimbursement is provided for the anesthesia service and it is not intended to guide the billing and reimbursement of anesthesia services.

Note: This document does not address moderate sedation. For more information on moderate sedation, please see the following:

For interventional pain management procedures, including but not limited to nerve blocks, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the following criteria have been met:

Note: Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Anesthesia services for interventional pain management procedures are considered not medically necessary for all other indications.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:
For the following anesthesia procedures related to pain management services

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Note: The following list of anesthesia service modifiers is for informational purposes:

Interventional pain management procedures are typically performed to diagnose or treat chronic pain conditions. These procedures are often performed without the use of sedation or with moderate sedation administered or overseen by the practitioner performing the procedure. However, when the procedure is complex or when the individual has significant medical conditions, a second practitioner may be needed to provide MAC. MAC is an anesthetic service for a diagnostic or therapeutic procedure in which a qualified anesthesia practitioner (for example, an anesthesiologist or nurse anesthetist) provides sedation, monitors vital functions, and treats complications.

In the Position on Monitored Anesthesia Care (ASA, 2018), the American Society of Anesthesiologists (ASA) defines MAC as the following:

Monitored anesthesia care is a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include, but are not limited to, the nature of the procedure, the patient’s clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic). Unlike monitored anesthesia care, moderate sedation is a proceduralist directed service which does not include a qualified anesthesia provider’s periprocedural assessment and has the inherent limitations that are policy directed for the non-anesthesia qualified provider. Moderate sedation is a proceduralist directed service that may be governed by separate institutional policies.

Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

Monitored anesthesia care may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesiologist provider of monitored anesthesia care must be prepared to convert to general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of procedure and position in the management in induction of general anesthesia when necessary.

The ASA, in a Statement on Anesthetic Care During Interventional Pain Procedures for Adults (ASA, 2021), states the following:

Use of sedation and/or anesthesia during the performance of pain procedures requires balancing the needs of the patient with the potential risks. The Committee recognizes the provision of procedural sedation or anesthesia as a separate and distinct service from the pain procedure, thus requiring specific training and credentialing as detailed in the ASA “Statement on Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals.” When sedation is provided during the performance of a pain procedure, it should allow the patient to be responsive during critical portions of the procedure, e.g., to report potential procedure-related paresthesia, acute changes in pain intensity or function, or potential toxicities.

Interventional pain procedures generally only require local anesthesia; however, patients may elect to also receive supplemental sedation. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can prescribe minimal sedation/analgesia (anxiolysis) or moderate (conscious) sedation as part of the procedure. For a limited number of patients, an anesthesia care team may be required (see ASA “Statement on the Anesthesia Care Team”). Examples of procedures that typically do not require moderate sedation or an anesthesia care team include but are not limited to epidural steroid injections; epidural blood patch; trigger point injections; shoulder, hip, sacroiliac, facet and knee joint injections; medial branch nerve blocks; and peripheral nerve blocks.

Significant patient anxiety and/or medical comorbidities may be an indication for moderate (conscious) sedation or anesthesia care team services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require moderate sedation or anesthesia care team services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral, and hypogastric); chemical or radiofrequency ablation; percutaneous discectomy; vertebral augmentation procedures; trial spinal cord stimulator lead placement; permanent spinal cord stimulator generator and lead implantation; and intrathecal pump implantation.

Anesthesia services are not the same as moderate (conscious) sedation. For more information, see the ASA Statements “Distinguishing Monitored Anesthesia Care (‘MAC’) from Moderate Sedation/Analgesia (Conscious Sedation)” and “Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia.”

Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)

ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

Subject: Anesthesia Services for Interventional Pain Management Procedures
Guideline #: CG-MED-78	Publish Date: 09/27/2023
Status: Reviewed	Last Review Date: 08/10/2023

CPT
01937	Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic
01938	Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral
01939	Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic
01940	Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral
01941	Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic
01942	Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral
01991	Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position
01992	Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position

ICD-10 Diagnosis
	All diagnoses

	CPT Physical Status Modifiers
P1	A normal healthy patient (Class I)
P2	A patient with mild systemic disease (Class II)
P3	A patient with severe systemic disease (Class III)
P4	A patient with severe systemic disease that is a constant threat to life (Class IV)
	HCPCS Anesthesia Modifiers
G8	Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9	Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
QS	Monitored anesthesia care service

Status	Date	Action
Reviewed	08/10/2023	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised References and Websites sections. Updated Coding section with informational note regarding CPT and HCPCS modifiers.
Reviewed	08/11/2022	MPTAC review. Updated References and Websites sections.
	12/29/2021	Updated Coding section with 01/01/2022 CPT changes; added 01937-01942 effective 01/01/2022 replacing 01935, 01936 deleted 12/31/2021.
Reviewed	08/12/2021	MPTAC review. References, Websites for Additional Information, and Appendix sections updated.
Reviewed	08/13/2020	MPTAC review. References, Websites, and Appendix sections updated. Reformatted Coding section.
Reviewed	08/22/2019	MPTAC review. Discussion/General Information, References and Websites sections updated.
New	11/08/2018	MPTAC review. Initial document development.