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ModifiedCignaPolicy 0551

Anesthesia Services for Interventional Pain Management Procedures in an Adult

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This policy governs coverage of moderate sedation, monitored anesthesia care, or anesthesia administered during outpatient interventional pain management procedures for adults age 18 and older when specified risk factors or significant medical conditions reduce procedural safety.

Policy Summary

PayerCigna

PolicyAnesthesia Services for Interventional Pain Management Procedures in an Adult

Policy CodePolicy 0551

Change TypeModified

Effective DateSep 15, 2026

Next Review DateFeb 15, 2027

Key ActionSubmit claims with applicable covered procedure and diagnosis codes.

SourceLink

POLICY UPDATE CHANGES

The policy statement for moderate sedation and monitored anesthesia care during interventional pain procedures was revised in the annual review.

2Anesthesia service categories addressed

18+Minimum patient age

BMI ≥40Morbid-obesity criterion

8MAC CPT codes listed

All other codesDiagnosis codes not covered

Coverage Criteria

Adult Outpatient Procedure With Qualifying Safety Risk

Coverage may be medically necessary for an adult undergoing an outpatient interventional pain management procedure when the procedure presents a qualifying safety risk due to certain risk factors or significant medical conditions.

ALL of the following

The individual is an adult age 18 or over.
The individual is undergoing an outpatient interventional pain management procedure, including diagnostic or therapeutic nerve blocks, neurolytic blocks, injections, or percutaneous image-guided procedures such as trigger point injections, epidural steroid injections, epidural blood patches, facet joint injections, peripheral or spinal nerve root blocks, peripheral or spinal neurolytic blocks, sacroiliac or other joint injections, radiofrequency ablation, spinal cord stimulator implantation, or intrathecal infusion device implantation.
ANY of the following qualifying safety risks or conditions is present
- The procedure requires the individual to remain motionless for a prolonged period or in a painful position.

Policy Summary

PayerCigna

PolicyAnesthesia Services for Interventional Pain Management Procedures in an Adult

Policy CodePolicy 0551

Change TypeModified

Effective DateSep 15, 2026

Next Review DateFeb 15, 2027

Key ActionSubmit claims with applicable covered procedure and diagnosis codes.

SourceLink

On This Page

Moderate Sedation

Moderate sedation for an adult undergoing an interventional pain management procedure is considered medically necessary when EITHER of the following criteria is met:

EITHER of the following

The interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position, including sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of a spinal cord stimulator, or implantation of an intrathecal infusion device.
BOTH of the following
- ANY of the following interventional pain procedures is being performed
  - Epidural steroid injection.
  - Epidural blood patch.
  - Facet joint injection.
  - Peripheral and/or spinal nerve root block.
  - Peripheral and/or spinal neurolytic block.
  - Sacroiliac joint injection.
- Severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, another severe psychiatric condition, or severe cognitive impairment would risk endangering the individual's safety during the planned procedure.

Monitored Anesthesia Care

Monitored anesthesia care (MAC), including use of general anesthesia as an intravenous anesthetic without a secured airway, is considered medically necessary for an adult undergoing an interventional pain management procedure when EITHER of the following criteria is met:

EITHER of the following

The interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position, including sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of a spinal cord stimulator, or implantation of an intrathecal infusion device.
BOTH of the following
- ANY of the following interventional pain procedures is being performed
  - Epidural steroid injection.
  - Epidural blood patch.
  - Facet joint injection.
  - Peripheral and/or spinal nerve root block.
  - Peripheral and/or spinal neurolytic block.
  - Sacroiliac joint injection.
- ANY of the following risk factors or conditions is present
  - Increased risk for complications due to ASA physical status III or above.
  - Severe cardiac disease and/or pulmonary disease, such as severe hypotension (systolic blood pressure < 90 mm Hg) or major cardiac dysfunction.
  - Documented sleep apnea.
  - Morbid obesity.BMI >= 40 kg/m²
  - Chronic renal failure.eGFR < 60 ml/min/1.73 m² for more than 3 months, or stage 3A or higher

Coding and Diagnosis Codes

Table 1: Moderate SedationCPTCovered

99152
99153
99156
99157

Table 2: Interventional Pain Management ProcedureCPTCovered

27096
62273
62281
62320
62321
62322
62323
62324
62327
64479

1–10 of 17

1/2

Table 2: Interventional Pain Management ProcedureHCPCSCovered

G0260

Diagnosis CodesICD-10

F01.50
F01.511
F01.518
F01.52
F01.53
F01.54
F01.A0
F01.A11
F01.A18
F01.A2

1–10 of 56

1/6

Table 2 interventional pain management procedure diagnosis codesICD-10Covered

F02.A18
F02.A2
F02.A3
F02.A4
F02.B0
F02.B11
F02.B18
F02.B2
F02.B3
F02.B4

1–10 of 73

1/8

Not Covered or ReimbursableICD-10Not Covered

All other codes

Monitored Anesthesia Care (MAC) CPT CodesCPTCovered

01937
01938
01939
01940
01941
01942
01991
01992

Monitored Anesthesia Care (MAC) HCPCS CodesHCPCSCovered

G9654

Interventional Pain Management Procedure CPT CodesCPTCovered

27096
62281
62321
62322
62323
62324
62325
62326
62327
64479

1–10 of 19

1/2

Interventional Pain Management Procedure HCPCS CodesHCPCSCovered

G0260

Interventional Pain Management Procedure ICD-10-CM Diagnosis CodesICD-10Covered

E66.01
E66.2
E84.0
E84.11
E84.9
F01.50
F01.511
F01.518
F01.52
F01.53

1–10 of 87

1/9

Alcohol-related diagnosis codesICD-10

F10.14
F10.150
F10.151
F10.159
F10.180
F10.188
F10.19
F10.221
F10.230
F10.231

1–10 of 30

1/3

Opioid- and cannabis-related diagnosis codesICD-10

F11.10
F11.120
F11.121
F11.122
F11.129
F11.14
F11.150
F11.151
F11.159
F11.188

1–10 of 31

1/4

Cannabis- and sedative-related diagnosis codesICD-10

F12.150
F12.151
F12.159
F12.180
F12.188
F12.19
F12.20
F12.222
F12.23
F12.259

1–10 of 35

1/4

Sedative- and cocaine-related diagnosis codesICD-10

F13.259
F13.280
F13.288
F13.920
F13.921
F13.929
F13.930
F13.931
F13.932
F13.939

1–10 of 24

1/3

Cocaine- and other-stimulant-related diagnosis codesICD-10

F14.14
F14.150
F14.151
F14.159
F14.180
F14.188
F14.19
F14.20
F14.21
F14.222

1–10 of 30

1/3

Other-stimulant- and hallucinogen-related diagnosis codesICD-10

F15.150
F15.151
F15.159
F15.180
F15.188
F15.19
F15.20
F15.21
F15.222
F15.259

1–10 of 31

1/4

Hallucinogen- and other-psychoactive-substance-related diagnosis codesICD-10

F16.150
F16.151
F16.159
F16.180
F16.183
F16.188
F16.19
F16.20
F16.21
F16.259

1–10 of 38

1/4

Other psychoactive substance diagnosis codesICD-10

F19.20
F19.21
F19.222
F19.259
F19.280
F19.288
F19.90
F19.920
F19.921
F19.922

1–10 of 17

1/2

Diagnosis CodesICD-10

F19.20
F19.21
F19.222
F19.259
F19.280
F19.288
F19.90
F19.920
F19.921
F19.922

1–10 of 24

1/3

Diagnosis CodesICD-10

F30.13
F31.13
F31.2
F31.4
F31.5
F31.63
F31.64
F41.0
F41.1
F43.22

1–10 of 30

1/3

Diagnosis CodesICD-10

G20.A1
G20.A2
G20.B1
G20.B2
G20.C
G21.11
G21.19
G21.2
G21.3
G21.4

1–10 of 37

1/4

Diagnosis CodesICD-10

G40.009
G40.019
G40.109
G40.119
G40.209
G40.219
G40.309
G40.319
G40.A09
G40.A19

1–10 of 26

1/3

Diagnosis CodesICD-10

G47.30
G47.31
G47.33
G47.34
G47.36
G47.37
G47.39
G70.80
G70.81
G73.1

1–10 of 17

1/2

Diagnosis CodesICD-10

I12.0
I13.11
I13.2
I21.3
I25.3
I25.41
I25.42
I25.5
I25.6
I27.21

1–10 of 40

1/4

Diagnosis CodesICD-10

K13.29
K70.0
K70.10
K70.11
K70.2
K70.30
K70.31
K70.40
K70.41
K70.9

1–10 of 40

1/4

Listed ICD-10-CM Diagnosis CodesICD-10Covered

I47.19
I47.20
I47.21
I47.22
I47.29
I47.9
I50.84
I51.7
K13.29
K70.0

1–10 of 72

1/8

Not Covered or ReimbursableICD-10Not Covered

All other codes

Renal-function threshold

ThresholdeGFR < 60 ml/min/1.73 m² for more than 3 months, or stage 3A or higher

ConditionChronic renal failure

ContextListed as a comorbidity that increases risk for complications with monitored anesthesia care

Liver-disease threshold

ThresholdMELD score > 10

ConditionChronic liver disease

ContextListed as a comorbidity that increases risk for complications with monitored anesthesia care

Morbid-obesity threshold

ThresholdBMI ≥ 40 kg/m²

ConditionMorbid obesity

ContextListed as a comorbidity that increases risk for complications with monitored anesthesia care

Age threshold

ThresholdAge > 70 years

Risk factorOlder age

ContextListed as a comorbidity that increases risk for complications with monitored anesthesia care

Severe-hypotension threshold

ThresholdSystolic blood pressure < 90 mm Hg

ConditionSevere hypotension

ContextExample of severe cardiac or pulmonary disease that increases risk for complications

Adult age requirement

Minimum age18 years or over

Eligible populationAdults undergoing an interventional pain management procedure

ExclusionThe policy does not apply to children under 18 years of age

Anesthesiologist evaluation threshold

ThresholdBMI > 40 kg/m²

ConditionMorbid obesity

Management requirementRequires evaluation and management of procedural sedation and analgesia by an anesthesiologist

Chronic renal-failure threshold

Renal-function thresholdGlomerular filtration rate below 60 ml/min/1.73 m² for more than 3 months

Alternative stage thresholdStage 3A

ConditionChronic renal failure

Chronic liver-disease threshold

ThresholdMELD score ≥ 10

ConditionChronic liver disease

Management requirementRequires evaluation and management of procedural sedation and analgesia by an anesthesiologist

Age risk-factor threshold

ThresholdAge greater than 70 years

Risk factorOlder age

Management requirementRequires evaluation and management of procedural sedation and analgesia by an anesthesiologist

Provider and Billing Actions

Denial Risk

Age, Diagnosis, and Coding Exclusions

Bill anesthesia services only for adults age 18 or older undergoing an interventional pain management procedure covered by this policy. Claims may be denied when the patient is under 18, the diagnosis or procedure is outside policy criteria, or the claim does not include the applicable covered codes.

Age exclusion: The policy does not apply to children under 18.
Use the most appropriate covered diagnosis and procedure codes effective on the date of service.
Services billed for non-covered conditions or without applicable covered codes are not reimbursable.

Denial Risk

Moderate Sedation for Excluded Indications

Moderate sedation is not covered or reimbursable when furnished for an excluded indication or for any indication other than those meeting the policy criteria.

Excluded examples include trigger point injection and peripheral joint injection, such as knee, shoulder, or wrist injection.
Confirm that the procedure and qualifying clinical indication satisfy the moderate-sedation criteria before billing.

Denial Risk

MAC Without a Qualifying Indication

MAC is not covered or reimbursable for an indication that does not meet the policy criteria for an adult undergoing an interventional pain management procedure.

Excluded examples include cases when no anesthetic is administered, trigger point injection, and peripheral joint injection, such as knee, shoulder, or wrist injection.
Document the qualifying patient risk factor or significant medical condition supporting MAC.

Documentation Required

Stable Condition Alone Does Not Establish MAC Necessity

The presence of a stable, treated condition alone does not establish the medical necessity of MAC. Document the specific condition, its clinical significance, and why it creates a safety concern during the planned procedure.

Do not rely solely on an ASA physical status classification or a stable diagnosis to support MAC.
Record the patient-specific risk and the rationale for requiring monitored anesthesia care.

Billing Rule

Deleted or Inactive Codes

Verify that every billed code was active and effective on the date the service was rendered. Deleted codes and codes not effective for the date of service may not be eligible for reimbursement.

Check current CPT and other applicable code sets before claim submission.
Do not submit deleted or inactive codes for services rendered after their effective period.

Denial Risk

Service or Patient Outside Policy Criteria

Coverage applies only when the patient, service, procedure, diagnosis, and anesthesia type satisfy the applicable policy criteria. Services or patients outside those criteria may be denied as not covered or not reimbursable.

The patient must be age 18 or older.
The service must involve an interventional pain management procedure addressed by the policy.
The applicable moderate-sedation or MAC criteria must be met and documented.

Billing Rule

Unlisted Diagnosis Codes

Diagnosis codes outside the applicable policy diagnosis table, including unlisted or otherwise non-covered ICD-10-CM codes, are not covered or reimbursable for the applicable anesthesia service.

Use a diagnosis code listed in the applicable policy table for the billed moderate sedation or MAC service.
Claims using an unlisted diagnosis code or an entry identified as “all other codes” may be denied.

Definitions

Severe anxiety

DefinitionSevere anxiety is being under active medical management

Medication managementPsychotropic medication may be used

Therapeutic managementCognitive therapy may be used

Interventional pain management procedures

Procedure categoryDiagnostic or therapeutic nerve blocks

Procedure categoryNeurolytic blocks

Procedure categoryDiagnostic or therapeutic injections

Procedure categoryPercutaneous image-guided procedures

ExamplesRadiofrequency ablation and implantation of spinal cord stimulators or intrathecal infusion devices

Monitored anesthesia care

DefinitionMonitored anesthesia care includes use of general anesthesia as an intravenous anesthetic without a secured airway

Patient populationAdult age 18 or over undergoing an interventional pain management procedure

Qualifying useMay be medically necessary when prolonged immobility or a painful position is required, or when a qualifying procedure and accepted risk factor are present

Moderate sedation

ServiceModerate sedation services for the adult interventional pain procedure

Age requirementAdult age 18 or over

Procedure settingInterventional pain management procedure

ASA physical status classification

ASA I (P1)Normal healthy patient

ASA II (P2)Patient with mild systemic disease

ASA III (P3)Patient with severe systemic disease

ASA IV (P4)Patient with severe systemic disease that is a constant threat to life

ASA V (P5)Moribund patient not expected to survive without the operation

ASA VI (P6)Declared brain-dead patient whose organs are being removed for donor purposes

Monitored anesthesia care coding definition

ServiceMonitored anesthesia care (MAC) anesthesia service

HCPCS codeG9654 — Monitored anesthesia care (MAC)

CPT codes01937, 01938, 01939, 01940, 01941, 01942, 01991, and 01992

Moderate sedation/analgesia

DefinitionDrug-induced depression of consciousness

Patient responseThe patient responds purposefully to verbal commands, alone or with light tactile stimulation

Airway and ventilationNo intervention is required to maintain a patent airway, and spontaneous ventilation is adequate

Cardiovascular functionUsually maintained

Monitored anesthesia care practitioner service

PractitionerAn anesthesia practitioner, such as an anesthesiologist or certified registered nurse anesthetist, who is not involved in the diagnostic or procedural service

Services providedMay provide varying levels of sedation, analgesia, and anxiolysis

Primary focusAirway, hemodynamic, and physiologic stability

ReadinessMust be prepared and qualified to convert to general anesthesia if necessary

Anesthesia

Pain controlAnesthesia provides pain control during procedures

Anxiety reliefAnesthesia provides relief of anxiety during procedures

Muscle relaxationAnesthesia provides muscle relaxation during procedures

Long-term opioid therapy

DurationThree or more months

FrequencyOpioids are used on most days

DefinitionUse of opioids on most days for three or more months

Anesthesia Services for Interventional Pain Management Procedures in an Adult

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Coverage Criteria

Coding and Diagnosis Codes

Provider and Billing Actions

Policy Background

Definitions