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:

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

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.