Cigna moderate sedation MAC Coverage Update

Coverage Criteria — Moderate Sedation & MAC

inv-01: Moderate Sedation - Medically Necessary

Moderate sedation for an adult (age 18 or over) undergoing an interventional pain management procedure is considered medically necessary when EITHER of the following criteria is met:

Criterion A: The interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (e.g., sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).

Criterion B

Procedures: Epidural steroid injection; epidural blood patch; facet joint injection; peripheral and/or spinal nerve root block; sacroiliac joint injection.
Patient factors: Severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, or other severe psychiatric condition(s), or severe cognitive impairment(s) that would risk endangering the individual's safety during the planned procedure.

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inv-02: Monitored Anesthesia Care (MAC) - Medically Necessary

Monitored anesthesia care (including use of general anesthesia without a secured airway) for an adult (age 18 or over) undergoing an interventional pain management procedure is considered medically necessary when EITHER of the following criteria is met:

Criterion B

Procedures: Epidural steroid injection; epidural blood patch; facet joint injection; peripheral and/or spinal nerve root block; sacroiliac joint injection.
Risk factors/comorbidities: Presence of increased risk for complications due to ASA physical status III or above OR any of: severe cardiac or pulmonary disease (e.g., severe hypotension, major cardiac dysfunction), documented sleep apnea, morbid obesity (BMI ≥ 40 kg/m2), chronic renal failure (eGFR < 60 ml/min/1.73 m2 for >3 months), chronic liver disease (MELD score > 10), age > 70 years, severe anxiety under active medical management, severe psychiatric or cognitive impairment, spasticity or movement disorder (e.g., cerebral palsy, dystonia, brain injury, stroke), individuals at risk of airway obstruction due to anatomical variation, anticipated tolerance/physical dependence to sedatives, or history of illicit drug or alcohol abuse.

inv-04: Monitored Anesthesia Care (MAC)

Monitored Anesthesia Care (MAC) considered medically necessary when ALL of the following are met:

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inv-03: Not Covered Indications for Moderate Sedation or MAC

Moderate sedation or MAC is not covered or reimbursable for any other indication, including the following:

Not covered examples: Trigger point injection; peripheral joint injection (e.g., knee, shoulder, wrist); when no anesthetic is administered (for MAC).

Moderate sedation and monitored anesthesia care (MAC) are intended for adults (age 18 or over) undergoing interventional pain procedures when specific clinical criteria are met. These services are not routinely indicated for procedures that are typically performed with local anesthesia alone. Examples excluded include trigger point injections and peripheral joint injections (e.g., knee, shoulder, wrist), which are listed as not covered or reimbursable when the sole purpose is to provide moderate sedation or MAC. Providers should reserve escalation to moderate sedation or MAC only when the policy’s medical necessity criteria (such as need to remain motionless for prolonged/painful positioning or documented severe anxiety under active management) are satisfied.

The policy identifies a group of ICD-10-CM diagnosis codes designated as Not Covered or Reimbursable. The Not Covered list is presented in the policy text and applies to claims for moderate sedation or MAC when those diagnosis codes are used. Claims submitted with diagnoses defined in that Not Covered list may be denied as not covered or not reimbursable under this policy.

All diagnosis codes that are not specifically included in Table 4 for interventional pain management procedures are labeled Not Covered or Reimbursable. In other words, only the ICD-10-CM codes listed in Table 4 support coverage for the interventional procedures and associated anesthesia services described in this policy; all other codes are not covered or reimbursable.

Coding — Procedure & Diagnosis Codes

Covered CPT Codes - Moderate Sedation (Table 1)CPTCovered

99152	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service; initial 15 minutes of intraservice time, patient age 5 years or older.
99153	Moderate sedation services provided by the same physician or other qualified health care professional; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
99156	Moderate sedation services provided by a physician or other qualified health care professional other than the physician performing the diagnostic or therapeutic service; initial 15 minutes of intraservice time, patient age 5 years or older.
99157	Moderate sedation services provided by a physician or other qualified health care professional other than the physician performing the diagnostic or therapeutic service; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

Interventional Pain Management Procedure Codes (Table 2)CPTCovered

27096	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.
62273	Injection, epidural, of blood or clot patch.
62281	Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic.
62320	Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT).
62322	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62323	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT).
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62325	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT).
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.

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Interlaminar and transforaminal epidural injections (excerpt)CPT

62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT).
64479	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level.
64480	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure).
64483	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level.
64484	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure).

Facet joint/paravertebral injections (excerpt)CPT

64490	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; single level.
64491	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure).
64492	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure).
64493	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance, lumbar or sacral; single level.
64494	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure).
64495	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).

Sacroiliac and neurolytic procedures (excerpt)mixed

G0260	Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography.
27096	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.
62273	Injection, epidural, of blood or clot patch.
62281	Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic.

Monitored anesthesia care (Table 3)CPT | HCPCSCovered

01937	Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic.
01938	Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral.
01939	Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic.
01940	Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral.
01941	Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures on the spine or spinal cord; cervical or thoracic.
01942	Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures on the spine or spinal cord; lumbar or sacral.
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.
G9654	Monitored anesthesia care (MAC).

Selected ICD-10 diagnosis codes (excerpt)ICD-10

E66.01	Morbid (severe) obesity due to excess calories.
E66.2	Morbid (severe) obesity with alveolar hypoventilation.
E84.0	Cystic fibrosis with pulmonary manifestations.
F01.50	Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
F10.10	Alcohol abuse, uncomplicated.
F11.10	Opioid abuse, uncomplicated.

Table 4 ICD-10-CM diagnosis codes (full listing)ICD-10

F10.251	Alcohol dependence with alcohol-induced psychotic disorder with hallucinations.
F10.259	Alcohol dependence with alcohol-induced psychotic disorder, unspecified.
F10.26	Alcohol dependence with alcohol-induced persisting amnestic disorder.
F10.27	Alcohol dependence with alcohol-induced persisting dementia.
F10.280	Alcohol dependence with alcohol-induced anxiety disorder.
F10.288	Alcohol dependence with other alcohol-induced disorder.
F10.29	Alcohol dependence with unspecified alcohol-induced disorder.
F10.920	Alcohol use, unspecified with intoxication, uncomplicated.
F10.921	Alcohol use, unspecified with intoxication delirium.
F10.929	Alcohol use, unspecified with intoxication, unspecified.

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Covered ICD-10-CM Diagnosis Codes (Table 4)ICD-10Covered

G23.3	Hypomyelination with atrophy of the basal ganglia and cerebellum.
G23.8	Other specified degenerative diseases of basal ganglia.
G23.9	Degenerative disease of basal ganglia, unspecified.
G24.01	Drug induced subacute dyskinesia.
G24.02	Drug induced acute dystonia.
G24.09	Other drug induced dystonia.
G24.1	Genetic torsion dystonia.
G24.2	Idiopathic nonfamilial dystonia.
G24.3	Spasmodic torticollis.
G24.4	Idiopathic orofacial dystonia.

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Not Covered Diagnosis CodesICD-10Not Covered

All other codes

Not Covered or Reimbursable

inv-19: BMI for morbid obesity — key clinical threshold

BMI for morbid obesity>= 40 kg/m2

Clinical implicationMorbid obesity (BMI >= 40) is listed as a comorbidity that increases risk and supports need for MAC

Source contextReferenced in MAC risk criteria and professional society guidance for procedural sedation

inv-20: Age threshold — > 70 years (clinical threshold)

Age threshold

Provider Actions, Prior Auth & Documentation

Prior Authorization

Prior Authorization Required for Moderate Sedation Codes

Prior authorization is required for moderate sedation CPT codes when coverage depends on plan benefits and documented medical necessity. Requests should reference the applicable benefit plan, relevant laws/regulations, and the specific clinical facts for the date of service. Claims submitted without a covered code or without required authorization will be denied as not covered.

Prior authorization applies to CPT 99152, 99153, 99156, 99157 (Table 1).
Include the primary interventional procedure code (Table 2/4) with the sedation code on requests/claims.
Claims without covered codes per the member's plan will be denied.

Note

Monitored Anesthesia Care (MAC) — Medical Necessity

Monitored Anesthesia Care (MAC) codes are considered medically necessary when MAC (Table 3) is provided for adults (age ≥18) undergoing an interventional pain management procedure (Table 4) and all applicable policy criteria are met (e.g., patient comorbidity, procedural risk, and ASA/CMS guidance). MAC is provided by an anesthesia practitioner not performing the procedure.

Conservative Treatment Requirements

inv-43: Attempt standard local anesthesia/minimal sedation when clinically appropriate prior to escalation to moderate sedation or MAC.

Conservative treatment requirement:

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Imaging & Monitoring Requirements

Billing Rule

Imaging guidance specified in code descriptions

Multiple interventional injection CPT codes in Table 2 and Table 4 specify image guidance; when performing these procedures, use the imaging modality indicated (fluoroscopy or CT) as described in the code entries.

Examples: 27096, 62321, 62323, 62327 indicate image guidance (fluoroscopy or CT)
Follow the code descriptions that specify imaging guidance when billing and performing the procedure

Billing Rule

Fluoroscopy/CT required for listed transforaminal and facet injections

Transforaminal epidural injections, paravertebral facet joint injections, and many other interventional injections list 'with imaging guidance (fluoroscopy or CT)' in their code descriptions; ensure imaging guidance is provided and documented when using those CPT codes.

Transforaminal codes: 64479–64484 specify fluoroscopy or CT

Not Covered — Services & Codes

Trigger point injections and peripheral joint injections are explicitly listed as procedures for which moderate sedation or MAC is not covered or reimbursable. The policy states these procedures (for example, injections of the knee, shoulder or wrist, and trigger point injections) should not be billed with moderate sedation or MAC solely for sedation purposes, and such services will not meet the policy’s medical necessity criteria.

The policy includes a Not Covered or Reimbursable diagnosis code section. Codes listed in that Not Covered section (as presented in the policy tables and notes) are not acceptable for coverage of moderate sedation or MAC; claims using those diagnosis codes are subject to denial as not covered or not reimbursable under this policy.

Additional diagnosis codes not explicitly listed in Table 4 are regarded as outside the scope of covered indications. When a diagnosis is not present in Table 4, the policy’s Not Covered designation applies and reimbursement for anesthesia/sedation related to interventional pain procedures will not be supported.

The policy’s Not Covered statement is summarized succinctly as: All other codes — any ICD-10-CM diagnosis not listed in the policy’s Table 4 is classified as Not Covered or Reimbursable. Providers must ensure the billed diagnosis is one of the Table 4 codes to support coverage.

Background

Interventional pain procedures encompass a range of injections and image-guided interventions (for example, epidural steroid injections, epidural blood patch, facet joint injections, transforaminal epidural injections, sacroiliac joint injections, radiofrequency ablation, and implant procedures). These procedures are commonly performed with local anesthesia; supplemental sedation is reserved for situations meeting policy criteria. Moderate sedation permits patients to respond purposefully to verbal commands without significant airway compromise, while MAC involves an anesthesia practitioner focused on airway and physiologic stability and may include deeper levels of sedation up to general anesthesia when indicated.

Definitions

inv-40: Severe anxiety — definition (active medical management with psychotropic medication and/or cognitive therapy)

DefinitionSevere anxiety = under active medical management with psychotropic medication and/or cognitive therapy

Clinical roleSevere anxiety listed as a patient factor that may necessitate moderate sedation or MAC

Source contextDefinition appears in the policy overview and general background sections

inv-41: Monitored Anesthesia Care (MAC) — definition: anesthesia practitioner not involved in the diagnostic/procedural service

Definition of MACA service by an anesthesia practitioner not involved in the diagnostic/procedural service, focused on airway, hemodynamic, and physiologic stability, prepared to convert to general anesthesia if necessary

Provider role

Revision History & Policy Changes

Note

2025-02-15Annual reviewLatest

Annual review completed; no clinical policy statement changes noted on 02/15/2025.

2024-02-15Annual review

Annual review completed; no clinical policy statement changes noted on 02/15/2024.

2023-10-15

OpenPayer

Moderate Sedation and Monitored Anesthesia Care for Interventional Pain Management