Commercial

Medical Policy

Notification

Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management

Notification Issue Date:

This policy will become effective xx/xx/xxxx.

The following new policy has been developed to communicate the Company's coverage criteria for anesthesia services of monitored anesthesia care (MAC) for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management.

Title:

Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management

Policy #:

01.00.12d

Policy

General anesthesia (GA) or monitored anesthesia care (MAC) services for epidural, paravertebral facet, and sacroiliac joint injections is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use. GA or MAC is rarely if ever required; however, it may be covered for epidural, paravertebral facet, and sacroiliac joint injections based on the individual's unique clinical circumstances, for the following:

Individuals with increased risk for complications due to severe comorbidity (American Society of Anesthesiologists [ASA] Physical Status Classification Level III or IV) must be supported and documented in the medical records indicating the following:

An individual with severe systemic disease
An individual with severe systemic disease that is a constant threat to life

Individuals with morbid obesity (body mass index [BMI] >40)
Individuals with documented sleep apnea requiring both bilevel positive airway pressure (BiPAP) and supplemental oxygen during sleep
Individuals for whom a behavioral health professional has determined that severe anxiety, psychiatric condition(s), or cognitive impairment(s) would decrease patient safety during the procedure
Individuals with a hyperkinetic movement disorder, such as, but not limited to, the following:

Epilepsy
Multiple sclerosis
Parkinson's disease
Cerebral palsy

Individuals with increased risk for airway obstruction due to anatomic variation such as but not limited to the following:

History of stridor
Dysmorphic facial features
Oral abnormalities (e.g., macroglossia)
Neck abnormalities (e.g., neck mass)
Jaw abnormalities (e.g., micrognathia)
Mallampati score of 4
Pierre Robin syndrome
Trisomy 21

GA and MAC are subject to medical necessity documentation review when used in epidural, paravertebral facet, and sacroiliac joint injections used for interventional pain management.

Note: When GA or MAC is used during the performance of an epidural, paravertebral facet, or sacroiliac joint injection, the individual must be responsive during the critical portions of the procedure in order to report any procedure-related change in pain intensity, function, and/or paresthesia.

Standard medical practice utilizes local anesthesia or conscious sedation for epidural, paravertebral facet, and sacroiliac joint injections used for interventional pain management.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

For epidural, paravertebral facet, and sacroiliac joint injections used for interventional pain management, which require utilization of additional anesthesia services (e.g., GA, MAC), the individual's medical record documentation should support, in the history and physical notes, the medical indications requiring the additional anesthesia service. The indications should be recorded by both the anesthesiologist/anesthetist and the professional provider performing the injection in their respective notes.

The use of additional anesthesia services (e.g., GA, MAC) provided by an anesthesiologist/anesthetist other than the professional provider performing an epidural, paravertebral facet, and sacroiliac joint injection used for interventional pain management will be reviewed on a case-to-case basis on review of the documentation in the individual's medical record that any of the specific coexisting risk factors exist.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

To indicate the administration of GA or MAC services for epidural, paravertebral facet, and sacroiliac joint injections, anesthesia providers must report CPT codes 01991 and 01992. These are the most specific codes utilized.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM

The purpose of the system is to assess and communicate the individual's preanesthesia medical comorbidities and provide a guideline for the anesthesiologist/anesthetist.

ASA I: A normal, healthy individual
ASA II: An individual with mild systemic disease
ASA III: An individual with severe systemic disease
ASA IV: An individual with severe systemic disease that is a constant threat to life
ASA V: A moribund individual who is not expected to survive without the operation
ASA VI: A declared brain-dead individual whose organs are being harvested

BODY MASS INDEX (BMI)

BMI is a measurement of excess adipose tissue in the body according to height and weight that is used to quantify body fat.

The BMI categories are:

Underweight: <18.5
Normal weight: 18.5–24.9
Overweight: 25–29.9
Obesity: ≥30
Morbid obesity: ≥40

MALLAMPATI TEST

The Mallampati test determines the size of the tongue in relation to the size of the oropharynx and the ability to open the mouth, which can indicate how easily the tongue can be displaced by a laryngoscope blade during intubation.

Class I: faucial pillars, soft palate, and entire uvula can be visualized
Class II: faucial pillars and soft palate can be visualized; the uvula is masked by the base of tongue
Class III: soft palate is only visible
Class IV: the soft palate is not visible; only the hard palate can be visualized at the roof of the mouth

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, general anesthesia (GA) or monitored anesthesia care (MAC) services are covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Description

GENERAL ANESTHESIA

General anesthesia is a drug-induced loss of consciousness during which the individual is not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Individuals often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

MINIMAL SEDATION

Minimal sedation, also called anxiolysis, is a drug-induced state during which individuals are relaxed and respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are unaffected.

MODERATE SEDATION

Moderate sedation, also called conscious sedation, involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the individual's ability to respond to stimulation and verbal commands. Moderate (“conscious") sedation is administered by the professional provider performing the procedure or an independent professional provider assisting in monitoring the individual's level of consciousness and physiological status. It includes pre- and postsedation evaluations, administration of the sedation, and monitoring of the cardiorespiratory function.

MONITORED ANESTHESIA CARE (MAC)

Monitored anesthesia care (MAC) is a specific anesthetic service used for a diagnostic or therapeutic procedure in which a qualified anesthesia professional provider (e.g., anesthesiologist, certified registered nurse anesthetist) who is not involved in performing the diagnostic or therapeutic procedure, provides sedation, monitors vital functions, and treats complications.

The American Society of Anesthesiologists (ASA), in a position statement "Position on Monitored Anesthesia Care" published in 2018, stated that the indications for monitored anesthesia care include, but are not limited to, the nature of the procedure, the individual'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 may include varying levels of sedation, awareness, analgesia, and anxiolysis as necessary. The qualified anesthesiology 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.

References

Alzanbagi AB, Jilani TL, Qureshi LA, et al. Randomized trial comparing general anesthesia with anesthesiologist-administered deep sedation for ERCP in average-risk patients. Gastrointest Endosc. 2022;96(6):983-990.e2.

American Society of Anesthesiologists (ASA). 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. [ASA Web site]. 03/2018. Available at: https://pubs.asahq.org/anesthesiology/article/128/3/437/18818/Practice-Guidelines-for-Moderate-Procedural. Accessed June 10, 2025.

American Society of Anesthesiologists (ASA). Statement on Distinguishing Monitored Anesthesia Care ("MAC") from Moderate Sedation/Analgesia (Conscious Sedation). [ASA Web site]. 10/18/2023. https://www.asahq.org/standards-and-practice-parameters/statement-on-distinguishing-monitored-anesthesia-care-from-moderate-sedation-analgesia. Accessed June 10, 2025.

American Society of Anesthesiologists (ASA). Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. [ASA Web site]. 10/23/2019. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia. Accessed June 10, 2025.

American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. [ASA Web site]. 10/13/2021. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-anesthetic-care-during-interventional-pain-procedures-for-adults. Accessed June 10, 2025.

American Society of Anesthesiologists (ASA). ASA physical status classification system. [ASA Web site]. 12/13/2020. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system. Accessed June 10, 2025.

American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017.

Anesthesia Airway Management (AAM). Pre-operative Airway Assessment. [AAM Web site]. 2022. Available at: https://aam.ucsf.edu/pre-operative-airway-assessment. Accessed June 10, 2025.

Anesthesia Patient Safety Foundation (APSF). Hazards of sedation for interventional pain procedures. [APSF Web site]. Fall 2012. Available at: https://www.apsf.org/article/hazards-of-sedation-for-interventional-pain-procedures/. Accessed June 10, 2025.

ASGE Standards of Practice Committee, Early DS, Lightdale JR, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018;87(2):327-337.

Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med. 2008;33(5):449-460.

Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology. 2007;133(2):675-701.

Das S, Ghosh S. Monitored Anesthesia Care: an overview. J Anaesthesiol Clin Pharmacol. 2015;31(1):27-29.

Kaye AD, Jones MR, Viswanath O, et al. ASIPP guidelines for sedation and fasting status of patients undergoing interventional pain management procedures. Pain Physician. 2019;22:201-207.

McCarty TR, Hathorn KE, Creighton DW, et al. Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis. Surg Endosc. 2021;35(12):6977-6989.

Novitas Solutions Inc. Medicare Services. Local Coverage Determination (LCD) L35049. Monitored Anesthesia Care. [Novitas Solutions Web site]. Original 10/01/2015. (Revised 10/17/2019). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35049&ver=58&bc=0. Accessed June 10, 2025.

Novitas Solutions Inc. Local Coverage Article (A57361) Billing and Coding: Monitored Anesthesia Care. [Novitas Web Site]. Original: 10/01/2019. (Revised 01/01/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57361&ver=37&bc=0. Accessed June 10, 2025.

Novitas Solutions Inc. Local Coverage Article (A58405) Billing and Coding: Facet Joint Interventions for Pain Management. [Novitas Web Site] Original: 04/25/2021. (Revised: 11/06/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58405&ver=10&bc=0. Accessed June 10, 2025.

Novitas Solutions Inc. Local Coverage Determination. (LCD) L34982. Lumbar Epidural Injections. [Novitas Solutions Web site]. Original: 10/01/2015. (Retired 06/20/2022). Available at: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=34982:36. Accessed June 10, 2025.

Novitas Solution Inc. Local Coverage Determination. (LCD) L34892. Facet Joint Interventions for Pain Management. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 08/11/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34892. Accessed June 10, 2025.

Novitas Solutions, Inc. Local Coverage Determination. (LCD L34993. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. [Novitas Web site]. Original: 10/01/2015. (Retired 04/21/2021). Available at: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=34993:31. Accessed June 10, 2025.

Novitas Solutions, Inc. Local Coverage Determination. (LCD) L34995. Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy. [Novitas Web site]. Original: 10/01/2015. (Retired 04/24/2021). Available at: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=34993:31. Accessed June 10, 2025.

Novitas Solutions Inc. Local Coverage Determination (LCD) L36920: Epidural Steroid Injections for Pain Management. [Novitas Web site] Original: 05/04/2017. (Revised 12/12/2021). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36920&ver=92&bc=0. Accessed June 10, 2025.

Novitas Solutions Inc. Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain Management. [Novitas Web site] Original: 04/25/2021. (Revised 07/07/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38803&ver=12&bc=0. Accessed June 10, 2025.

Purnell JQ, Feingold KR, Bradley A, et al. Definitions, Classification, and Epidemiology of Obesity. Endotext. 2018. Available at: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm. Accessed June 10, 2025.

Smith ZL, Mullady DK, Lang GD, et al. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc. 2019;89(4):855-862.

Spine Intervention Society (SIS). Conscious Sedation. [SIS Web site]. 02/2018. Available at: https://cdn.ymaws.com/www.ipsismed.org/resource/resmgr/factfinder/FactFinder_2018_02_Conscious.pdf. Accessed June 10, 2025.

Wu J, Li N, Zhang J, et al. Safety and efficacy of remifentanil-propofol combination on "muscle relaxant-free" general anesthesia for therapeutic endoscopic retrograde cholangiopancreatography: a randomized controlled trial. Am J Transl Res. 2023;15(8):5292-5303. Published 2023 Aug 15.

Coding

CPT Procedure Code Number(s)

01991, 01992

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 01.00.12d:

03/04/2026	This policy has been reviewed and reissued to communicate the Company’s continuing position on anesthesia services for epidural, paravertebral facet and sacroiliac joint injections for spinal joint management.
10/01/2025	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the ICD-10 CM code update, effective 10/01/2025. The following ICD-10 CM code has been deleted from this policy: G35 Multiple sclerosis The following ICD-10 CM codes been added to this policy: G35.A Relapsing-remitting multiple sclerosis G35.B0 Primary progressive multiple sclerosis, unspecified G35.B1 Active primary progressive multiple sclerosis G35.B2 Non-active primary progressive multiple sclerosis G35.C0 Secondary progressive multiple sclerosis, unspecified G35.C1 Active secondary progressive multiple sclerosis G35.C2 Non-active secondary progressive multiple sclerosis G35.D Multiple sclerosis, unspecified

03/04/2026

This policy has been reviewed and reissued to communicate the Company’s continuing position on anesthesia services for epidural, paravertebral facet and sacroiliac joint injections for spinal joint management.

10/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the ICD-10 CM code update, effective 10/01/2025.

The following ICD-10 CM code has been deleted from this policy:

G35 Multiple sclerosis

The following ICD-10 CM codes been added to this policy:

G35.A Relapsing-remitting multiple sclerosis
G35.B0 Primary progressive multiple sclerosis, unspecified
G35.B1 Active primary progressive multiple sclerosis
G35.B2 Non-active primary progressive multiple sclerosis
G35.C0 Secondary progressive multiple sclerosis, unspecified
G35.C1 Active secondary progressive multiple sclerosis
G35.C2 Non-active secondary progressive multiple sclerosis
G35.D Multiple sclerosis, unspecified

Revisions From 01.00.12c:

08/06/2025	This policy has been reissued in accordance with the Company's annual review process.
10/01/2024	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified and updated for the ICD-10 code update effective 10/01/2024. The following ICD-10 codes have been added to Attachment A of this policy: G40.841: KCNQ2-related epilepsy, not intractable, with status epilepticus G40.842: KCNQ2-related epilepsy, not intractable, without status epilepticus G40.843: KCNQ2-related epilepsy, intractable, with status epilepticus G40.844: KCNQ2-related epilepsy, intractable without status epilepticus

08/06/2025

This policy has been reissued in accordance with the Company's annual review process.

10/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified and updated for the ICD-10 code update effective 10/01/2024.

The following ICD-10 codes have been added to Attachment A of this policy:

G40.841: KCNQ2-related epilepsy, not intractable, with status epilepticus
G40.842: KCNQ2-related epilepsy, not intractable, without status epilepticus
G40.843: KCNQ2-related epilepsy, intractable, with status epilepticus
G40.844: KCNQ2-related epilepsy, intractable without status epilepticus

Revisions From 01.00.12b:

06/12/2024	The policy has been reviewed and reissued to communicate the Company's continuing position on Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management.
10/01/2023	This policy has been identified and updated for the ICD1-10 code update effective 10/01/2023. The following ICD1-10 codes have been added to Attachment A of this policy: G37.81, G37.89, G40.C01, G40.C09, G40.C11, and G40.C19. The following ICD1-10 code has been termed from Attachment A of this policy: G37.8

06/12/2024

The policy has been reviewed and reissued to communicate the Company's continuing position on Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management.

10/01/2023

This policy has been identified and updated for the ICD1-10 code update effective 10/01/2023.

The following ICD1-10 codes have been added to Attachment A of this policy: G37.81, G37.89, G40.C01, G40.C09, G40.C11, and G40.C19.

The following ICD1-10 code has been termed from Attachment A of this policy: G37.8

Revisions From 01.00.12a:

05/17/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management.
10/01/2022	This version of the policy will become effective 10/01/2022. Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. The following ICD1-10 CM narrative has been revised in Attachment A of this policy: G31.84: FROM: Mild cognitive impairment, so stated TO: Mild cognitive impairment of uncertain or unknown etiology The following ICD-10 CM codes have been added to Attachment A of this policy: F06.70 and F06.71.

05/17/2023

10/01/2022

This version of the policy will become effective 10/01/2022.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD1-10 CM narrative has been revised in Attachment A of this policy:

G31.84:

FROM: Mild cognitive impairment, so stated

TO: Mild cognitive impairment of uncertain or unknown etiology

The following ICD-10 CM codes have been added to Attachment A of this policy: F06.70 and F06.71.

Revisions From 01.00.12:

04/11/2022

This policy will become effective 04/11/2022.

The policy has been developed to communicate the Company's coverage criteria for anesthesia services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management.

Version Effective Date:

10/1/2025

Version Issued Date:

10/2/2025

Version Reissued Date:

3/4/2026