Clinical UM Guideline

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.

Note: Please see the following document for additional information on moderate sedation:

• CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation

Note: This document does not address whether or not reimbursement is provided for the anesthesia service and is not intended to explain the billing and reimbursement of anesthesia.

Medically Necessary:

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:

1. There is documentation that the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure; and
2. The medical condition or procedure must be significant enough to require the need for anesthesia services, including MAC. Such conditions or procedures may include, but are not limited to the following:
   1. Significant medical conditions (ASA physical status 3 or above) that increase risk for complications including cardiac disease, pulmonary disease, and morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m²); or
   2. Sleep apnea; or
   3. History of complications during sedation; or
   4. Severe anxiety, psychiatric conditions, or cognitive impairments that decrease safety during the procedure; or
   5. Spasticity or neurological conditions that decrease safety during the procedure; or
   6. Procedures requiring individuals to remain motionless for a prolonged period of time; or
   7. Procedures requiring individuals to remain in a painful position; or
   8. Individuals under the age of 18.

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.

Not Medically Necessary:

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.

As described by the American Society of Anesthesiologists (ASA) Statement on Distinguishing Monitored Anesthesia Care ("MAC") from Moderate Sedation/Analgesia (Conscious Sedation) (2023):

Monitored anesthesia care is a specific anesthesia service performed by a qualified (trained) anesthesia provider, for a diagnostic or therapeutic procedure. Indications for MAC 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). 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 MAC, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

• Preprocedural assessment and management of patient comorbidity and periprocedural risk
• Diagnosis and treatment of clinical problems that occur during the procedure
• Support of vital functions inclusive of hemodynamic stability, airway management, and appropriate management of the procedure induced pathologic changes as they affect the patient’s coexisting morbidities
• Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary for patient safety
• Psychological support and physical comfort
• Provision of other medical services as needed to complete the procedure safely
• Postoperative medical and pain management.

MAC may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesia provider of monitored anesthesia care must be prepared to manage all levels of sedation up to and including general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of the procedure and patient positioning. Please also refer to ASA’s Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.

Monitored Anesthesia Care can be distinguished from Moderate Sedation in several ways. Proceduralists providing moderate sedation may have their attention divided between their primary focus, the procedure, and secondary focus, patient sedation. Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s respiratory or cardiovascular functions or ability to maintain airway integrity. A provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC. These components of MAC are unique aspects of an anesthesia service that are not part of Moderate Sedation. In addition, MAC includes an array of post-procedure responsibilities beyond the expectations of practitioners providing Moderate Sedation, including assuring a return to baseline consciousness, relief of pain, management of adverse physiological responses or side effects from medications administered during the procedure, as well as the diagnosis and treatment of co-existing medical problems.

Monitored Anesthesia Care allows for the safe administration of a depth of sedation in excess of that provided during Moderate Sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during a procedure provides maximal flexibility in matching sedation level to a patient’s needs and procedural requirements. In situations where the procedure is more invasive, or when the patient is especially fragile, optimizing sedation level while maintaining cardiopulmonary function is necessary to achieve ideal procedural conditions.

In summary, MAC is an anesthesia service that is clearly distinct from Moderate Sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.

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.”

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Anesthesiologists (ASA). Statements and practice parameters. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters. Accessed on July 26, 2024.
   • ASA physical status classification system. Last amended December 13, 2020.
   • Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Committee of origin: Quality Management and Departmental Administration. Last amended October 23, 2019.
   • Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Last amended March 2018.
   • Statement on anesthetic care during interventional pain procedures for adults. Last amended October 13, 2021.
   • Statement on distinguishing monitored anesthesia care ("MAC") from moderate sedation/analgesia (conscious sedation). Original approval October 18, 2023.
   • Statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Last amended October 13, 2021.
   • Statement on granting privileges for deep sedation to non anesthesiologist physicians. Last amended October 26, 2022.
   • Statement on regional anesthesia. Last amended October 26, 2022.
   • Statement on the medical necessity of anesthesiology services. Last amended October 18, 2023.

1. National Institute of Health. NIH Pain Consortium. Available at: https://painconsortium.nih.gov/. Accessed on July 26, 2024.

Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)

American Society of Anesthesiology Physical Status Classifications:

ASA I    A normal healthy patient

ASA II   A patient with mild systemic disease

ASA III  A patient with severe systemic disease

ASA IV  A patient with severe systemic disease that is a constant threat to life

ASA V   A moribund patient who is not expected to survive without the operation

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

(ASA Physical Status Classification System, 2020)

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.

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