Subject:
Anesthesia Care During Interventional Pain Management Procedures
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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CMM-400: Anesthesia Care During Interventional Pain Management Procedures
| CMM-400.1: Definitions |
| CMM-400.2: General Guidelines |
| CMM-400.3: Indications |
| CMM-400.4: Non-Indications |
| CMM-400.5: Procedure (CPT®) Codes |
CMM-400.1: Definitions
† Conscious sedation includes:
® Minimal sedation (anxiolysis) indicates a drug-induced state during which members respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilation and cardiovascular functions are unaffected3.
® Moderate sedation/analgesia (conscious sedation) indicates a drug-induced depression of consciousness during which members respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained3.
® Deep sedation/analgesia is a drug-induced depression of consciousness during which members cannot be easily aroused but respond purposefully after repeated or painful stimulation3.
† Monitored anesthesia care (MAC) includes the administration of sedatives and/or analgesics often used for mild to moderate sedation. An essential component of MAC is the periprocedural anesthesia assessment and understanding of the member’s coexisting medical conditions and management of a member’s actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. The provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. MAC is administered by a certified registered nurse anesthetist (CRNA) or anesthesiologist. Additionally, a provider’s ability to intervene to rescue a member’s airway from any sedation-induced compromise is a a mandatory professional qualification to provide MAC7.
† General anesthesia is a drug-induced loss of consciousness during which members are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Members 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 impaired3.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-400.2: General Guidelines
† The determination of medical necessity for the performance of monitored anesthesia care (MAC) is always made on a case-by-case basis.
† The medical necessity of monitored anesthesia care (MAC) is:
® Evaluated prior to each procedure and the determination is made independent of any prior medical necessity determinations for monitored anesthesia care (MAC); and
® Only considered once an interventional pain procedure is approved or if the interventional pain procedure does not require prior authorization.
¡ Benefits, coverage policies, and eligibility issues pertaining to each health plan may take precedence over Horizon BCBSNJ’s guidelines. Providers are urged to obtain written instructions and requirements directly from each payor.
CMM-400.3: Indications
Monitored anesthesia care (MAC) is considered medically necessary when EITHER of the following are met:
† Monitored anesthesia care (MAC) will be used during ANY of the following interventional pain procedures8:
® Regional sympathetic blocks
® Radiofrequency ablation of the medial branch nerves
® Discography
® Spinal cord stimulator trial and permanent implantation
® Vertebral augmentation
® Implantation of intrathecal drug delivery systems
† There is a presence of ANY of the following:
® Attestation that a behavioral health professional has determined that severe anxiety, psychiatric condition(s), or cognitive impairment(s) would decrease member safety during the procedure13
® Hyperkinetic movement disorders including ANY of the following12:
¡ Acquired/traumatic/hypoxic brain injury/stroke
¡ Athetoid cerebral palsy
¡ Basal ganglia disease
¡ Dystonia
¡ Familial paroxysmal choreoathetosis
¡ Hemiballismus
¡ Huntington’s Chorea
¡ Multiple sclerosis
¡ Paroxysmal kinesigenic choreathetosis
¡ Spasticity related involuntary movements
¡ Spinal cord injury
® Members at risk for airway obstruction due to an anatomic variation including ANY of the following11,14:
¡ Dysmorphic facial features
¡ History of stridor
¡ Jaw abnormalities (e.g., micrognathia)
¡ Mallampati score of 4
¡ Neck abnormalities (e.g., mass)
¡ Oral abnormalities (e.g., macroglossia)
¡ Pierre-Robin syndrome
¡ Trisomy 21
® Significant medical condition that increases the risk for complications including ANY of the following10:
¡ Active hepatitis
¡ Cardiac disease including ANY of the following:
¡ Poorly controlled hypertension
¡ Implanted pacemaker/defibrillator
¡ Moderate to severe reduction in ejection fraction requiring medical treatment
¡ End stage renal disease requiring dialysis
¡ Morbid obesity (BMI ≥ 40 kg/m2)
¡ Pulmonary disease including poorly controlled COPD requiring oxygen
¡ Sleep apnea requiring BOTH of the following during sleep:
¡ BiPAP support
¡ Supplemental oxygen
When the criteria for the performance of monitored anesthetic care (MAC) are met, ALL of the following criteria must also be met6:
† A preoperative evaluation has been performed by a member of the anesthesia delivery team which includes airway examination and medical assessment.
† Informed consent has been obtained with a discussion of alternative sedation options.
† BOTH of the following are present during the delivery of monitored anesthesia care (MAC):
® Continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry
® A qualified medical professional to recognize and treat airway complications.
† Recovery from monitored anesthesia care (MAC) will be managed by skilled nursing personnel with direct supervision by a certified registered nurse anesthetist or anesthesiologist.
CMM-400.4: Non-Indications
† Monitored anesthesia care (MAC) for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine is considered investigational.
CMM-400.5: Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor. |
| CPT® | Code Description/Definition |
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 |
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 |
| CPT® | Code Considered Investigational |
00640 | Anesthesia for Manipulation of the Spine or for Closed Procedures on the Cervical, Thoracic or Lumbar Spine |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. |
Medicare Coverage:
There is no National Coverage Determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that this service may be covered when LCD L35049 criteria is met and the specific procedure is reasonable and necessary. For additional information and eligibility, refer to Local Coverage Determination (LCD): Monitored Anesthesia Care (L35049). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Local Coverage Article: Billing and Coding: Monitored Anesthesia Care (A57361). https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Anesthesia Care During Interventional Pain Management Procedures
Monitored Anesthesia Care, Pain Management Procedures
References:
1. Abram S, Francis M. Hazards of sedation for interventional pain procedures: the anesthesia patient safety foundation newsletter. 27(2):29-31.
2. American American Society of Anesthesiologists, Anesthesiology 2018; 128:437-79.
3. 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.
4. American Society of Anesthesiologists. Position on monitored anesthesia care. Last amended October 16, 2013.
5. 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.
6. 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.
7. American Society of Anesthesiologists. Standards and Guidelines Distinguishing Monitored Anesthesia Care from Moderate Sedation/Analgesia. October 17 2018.
8. American Society of Anesthesiologists. Statement on anesthetic care during interventional pain procedures for adults. Last amended October 26, 2016.
9. American Society of Anesthesiologists. Statement on regional anesthesia. Last amended October 25, 2017.
10. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. 2013; 118:251-70.
11. Early DS, Lightdale JR, Vargo JJ, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy. 2018;98(2)327-337. doi:10.1016/j.gie.2017.07.018.
12. Ene, H. Hyperkinetic movement disorders(including dystonias, choreas). PM&R Knowledge Now. 9/20/14
13. Spine Intervention Society FactFinders For Patient Safety. Conscious Sedation. February 2018.
14. Vargo JJ, Delegge MH, Feld AD, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. The American Journal of Gastroenterology. 2012. doi:10.1038/ajg.2012.112.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
01991
01992
01935
01936
00640
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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