Medicare Advantage

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 #:

MA01.008b

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.

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 in a constant threat to life

Individuals with morbid obesity (body mass index [BMI] ≥40)
Individuals with documented sleep apnea requiring both bilateral positive air 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 parasthesia.

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, that 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 general anesthesia or monitored anesthesia care 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

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM

The purpose of the system is to assess and communicate the individual's pre-anesthesia medical comorbidities and serves as 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 Evidence of Coverage, general anesthesia (GA) or monitored anesthesia care (MAC) services are covered under the medical benefits of the Company's Medicare Advantage 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 individuals are 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 post-sedation 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

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 April 26,2023.

American Society of Anesthesiologists (ASA). Position on Monitored Anesthesia Care. [ASA Web site]. 10/17/2018. Available at: https://www.asahq.org/standards-and-guidelines/position-on-monitored-anesthesia-care. Accessed April 26, 2023.

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-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia. Accessed April 26, 2023.

American Society of Anesthesiologist (ASA). Standards and guidelines distinguishing monitored anesthesia care from moderate sedation/analgesia. [ASA Web site]. 10/17/2018. Available at: https://www.asahq.org/standards-and-guidelines/distinguishing-monitored-anesthesia-care-MAC-from-moderate-sedationanalgesia-conscious-sedation. Accessed April 26, 2023.

American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. [ASA Web site]. 10/26/2018. Available at: https://www.asahq.org/standards-and-guidelines/statement-on-anesthetic-care-during-interventional-pain-procedures-for-adults. Accessed April 26, 2023.

American Society of Anesthesiologists (ASA). ASA physical status classification system. [ASA Web site]. 12/13/2020. Available at: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system. Accessed April 26, 2023.

Anesthesia Airway Management (AAM). Pre-operative Airway Assessment. [AAM Web site]. 2022. Available at: https://aam.ucsf.edu/pre-operative-airway-assessment#Mallampati-score. Accessed April 26, 2023.

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 April 26, 2023.

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.

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 April 26, 2023.

Novitas Solutions Inc. Local Coverage Article (A57361) Billing and Coding: Monitored Anesthesia Care. [Novitas Web Site]. Original: 10/01/2019. (Revised 10/01/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58405&ver=8&bc=0. Accessed April 26, 2023.

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=8. Accessed April 26, 2023.

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://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34982&ver=36&bc=0. Accessed April 26, 2023.

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 April 26, 2023.

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=34995:29. Accessed April 26, 2023.

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=90&bc=0. Accessed April 26, 2023.

Novitas Solutions Inc. Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain Management. [Novitas Web site] Original: 04/25/2021. (Revised 02/03/2022). Available at:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38803&ver=6&bc=0. Accessed April 26, 2023.

Purnell JQ, Feingold KR, BradleyA, et al. Definitions, Classifications and Epidemiology of Obesity. Endotext. 2018. Available at: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm. Accessed April 26, 2023.

Spine Intervention Society (SIS). Conscious Sedation. [SIS Web site]. 02/2018. Available at: https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2018_02_Conscious.pdf. Accessed April 26, 2023.

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 MA01.008b:

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 MA01.008a:

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 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

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 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 MA01.008:

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:

10/1/2023

Version Issued Date:

9/29/2023

Version Reissued Date: