Clinical UM Guideline

 

Subject: Anesthesia Services for Interventional Pain Management Procedures
Guideline #: CG-MED-78 Publish Date:    12/12/2018
Status: New Last Review Date:    11/08/2018

Description

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:

Clinical Indications

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.

Coding

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.

CPT

 

01935

Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic

01936

Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic

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

Discussion/General Information

Interventional pain management procedures are typically performed on individuals 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, 2013), the American Society of Anesthesiologists (ASA) defines MAC as the following:

Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient’s clinical condition and/or the potential need to convert to a general or regional anesthetic.

Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure visit, intraprocedure care and postprocedure anesthesia management. 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, analgesia and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.

The ASA, in a Statement on Anesthetic Care During Interventional Pain Procedures for Adults (ASA, 2016), states the following:

The use of moderate (conscious) sedation and/or anesthesia during the performance of pain procedures must be balanced with the potential risk of harm from doing pain procedures in sedated patients. The Committee recognizes the provision of sedation or anesthesia as a separate and distinct service from the pain procedure and thus requiring specific training…The Committee also notes that when moderate (conscious) 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 any procedure-related change in pain intensity, function and/or paresthesia.

Many patients can undergo interventional pain procedures without the need for supplemental sedation in addition to local anesthesia. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients a second provider may be required to manage moderate or deep sedation or, in selected cases other anesthesia services. Examples of procedures that typically do not require sedation include but are not limited to epidural steroid injections, epidural blood patch, trigger point injections, injections into the shoulder, hip, knee, facet, and sacroiliac joints, and occipital nerve blocks.

Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia 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 sedation or anesthesia services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral and hypogastric), chemical or radiofrequency ablation, percutaneous discectomy, trial spinal cord stimulator lead placement, permanent spinal cord stimulator generator and lead implantation, and intrathecal pump implantation. Major nerve/plexus blocks are performed less often in the chronic pain clinic, but the Committee believes that these blocks may more commonly require moderate (conscious) sedation or anesthesia services (e.g., brachial plexus block, sciatic nerve block, and continuous catheter techniques).

The Committee recognizes that pediatric patients may require sedation or anesthesia services for pain procedures because of age-related differences in the approach to this patient population.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists. Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. April 2010. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  2. American Society of Anesthesiologists. Position on monitored anesthesia care. Last amended October 16, 2013. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  3. American Society of Anesthesiologists. ASA physical status classification system. Last amended October 15, 2014. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  4. American Society of Anesthesiologists. 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 15, 2014. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  5. American Society of Anesthesiologists. Statement on anesthetic care during interventional pain procedures for adults. Last amended October 26, 2016. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  6. American Society of Anesthesiologists. Statement on regional anesthesia. Last amended October 25, 2017. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
  7. American Society of Anesthesiologists. 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. March 2018. For additional information visit the ASA website: http://www.asahq.org. Accessed on October 11, 2018.
Websites for Additional Information
  1. American Society of Interventional Pain Physicians. Available at: http://www.asipp.org/. Accessed on October 11, 2018.
  2. National Institute of Health. NIH Pain Consortium. Available at: https://painconsortium.nih.gov/. Accessed on October 11, 2018.
  3. Society for Pain Practice Management. Available at: http://www.sppm.org/. Accessed on October 11, 2018.
Index

Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)

History

Status

Date

Action

New

11/08/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.

Appendix

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, 2014)