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    v1.0.30
    OpenPayerPolicy UpdatesPain ManagementPriority Health Medicare Sedation Coverage | OpenP…
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    CurrentPriority Health MedicarePolicy 91632

    Moderate Sedation for Interventional Pain Management

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    This policy governs when moderate (conscious) sedation or anesthesia is medically necessary for adults undergoing interventional pain management procedures, subject to the member's specific benefits and applicable mandates.

    Policy Summary
    PayerPriority Health Medicare
    PolicyModerate Sedation for Interventional Pain Management
    Policy CodePolicy 91632
    Change TypeAdministrative/template updateno material clinical or coding change
    Effective DateJun 1, 2026
    Last ReviewMay 13, 2026
    Next Review DateN/A
    Key ActionReport modifier KX when the medical policy requirements have been met.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was converted to a new template with updated policy scope, medical and professional society guidelines, CMS regulatory references, and FDA/regulatory sections.

    The medical necessity sections were reorganized by combining former Section C with Section B to improve readability and reduce redundancy.

    The background section was updated and streamlined for clarity and consistency with current ASA, ASIPP, and Spine Intervention Society guidance.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Adults onlyAge limitation
    2 pathwaysMedical-necessity pathways
    7 proceduresEligible procedures when risk criteria are met
    2 exclusionsExplicit exclusions
    18+ yearsBilling-rule age threshold
    KXRequired modifier

    Medical Necessity and Coverage Criteria

    Inclusions: medically necessary moderate sedation

    Covered when either the procedure-related indication pathway is met, or both the medically necessary procedure and patient-specific risk-factor requirements are met.

    Moderate sedation medical necessity

    • Procedure-related indication: The interventional pain procedure requires the individual to remain motionless for a prolonged period or in a painful position.

    • Procedure and patient-specific risk factors

      • Medically necessary interventional pain procedure: One of the following procedures is being performed: epidural blood patch; epidural steroid injection; facet joint injection; medial branch block; peripheral and/or spinal nerve root block; sacroiliac joint injection; or sympathetic block.1 listed procedure
      • Documented patient-specific risk factor: At least one of the following is present: severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, another severe psychiatric condition, or severe cognitive impairment that could put the member's safety at risk during the planned procedure; documented needle phobia reported by the member; a documented history of previous interventional pain management procedures requiring moderate sedation to complete safely; or chronic opioid therapy contributing to sensitivity to pain.At least 1 risk factor

    Anesthesia and moderate sedation claim condition

    Anesthesia and moderate sedation services billed with pain management services for a patient 18 years of age or older are denied unless the following condition is met.

    Required surgical procedure: A surgical procedure in the range 10021-69990, other than a pain management procedure, is also present.10021-69990

    An exception applies for anesthesia services billed with modifiers indicating severe systemic disease (P3 or P4) or monitored anesthesia care (G9).

    For an adult undergoing an interventional pain management procedure other than a qualifying procedure, anesthesia or moderate sedation is not medically necessary for other indications, including trigger point injections and peripheral joint injections such as knee, shoulder, or wrist injections.

    This policy does not apply to children under 18 years of age.

    Anesthesia and moderate sedation for other pain management services are not covered unless they are performed with a surgical procedure.

    For patients 18 years of age or older, anesthesia and moderate sedation services billed with pain management services are denied when a surgical procedure in the range 10021–69990, other than a pain management procedure, is not also present. An exception applies to anesthesia services billed with modifiers P3, P4, or G9.

    Moderate sedation or anesthesia for an adult undergoing an interventional pain management procedure other than the qualifying procedures and indications described in the policy is not medically necessary.

    Codes and Billing Parameters

    ICD-10 Codes that may support medical necessityICD-10
    F41.1-F41.9Generalized anxiety disorder
    F40.231Fear of injections and transfusions
    F40.232Fear of other medical care
    F11.950-F11.959Opioid use, unspecified with opioid induced psychotic disorder
    F11.981-F11.988Opioid use, unspecified with other specified opioid induced disorder
    F03.90-F03.918Unspecified dementia
    ICD-10 Codes that may support medical necessityICD-10
    F41.1-F41.9Generalized anxiety disorder
    F40.231Fear of injections and transfusions
    F40.232Fear of other medical care
    F11.950-F11.959Opioid use, unspecified with opioid induced psychotic disorder
    F11.981-F11.988Opioid use, unspecified with other specified opioid induced disorder
    F03.90-F03.918Unspecified dementia
    CPT/HCPCS CodesCPT
    00300Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified
    00400Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified
    00600Anesthesia for procedures on cervical spine and cord; not otherwise specified
    00620Anesthesia for procedures on thoracic spine and cord, not otherwise specified
    00630Anesthesia for procedures in lumbar region; not otherwise specified
    01937Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic
    01938Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral
    01939Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic
    01940Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral
    01941Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures on the spine or spinal cord; cervical or thoracic
    1–10 of 30
    1/3
    Patient age
    Patient age18 years of age or older
    Applicable servicesAnesthesia and moderate sedation services billed with pain management services
    Billing ruleServices will be denied unless the required surgical procedure is also present; exceptions apply for modifiers P3, P4, or G9.
    Surgical procedure range
    Qualifying range10021-69990
    Procedure qualificationA surgical procedure other than a pain management procedure must also be present.

    Authorization, Documentation, and Billing Actions

    Prior Authorization

    Check Prior Authorization Requirements

    Check whether prior authorization is required before providing the drug, device, service, or procedure. When authorization is required, submit a request demonstrating medical necessity; refer to the Priority Health Provider Manual for details.

    Prior Authorization

    Obtain Individual Consideration Approval

    Individual case review may allow coverage for care or treatment that is investigational yet promising for the conditions described. Requests for individual consideration require prior plan approval and are reviewed by a Priority Health medical director or clinical pharmacist.

    • Exceptions to experimental, investigational, or unproven treatment exclusions may be reviewed for terminal illness or chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

    Clinical Background

    Moderate or conscious sedation is a drug-induced depression of consciousness in which the patient responds purposefully to verbal commands, either alone or with light tactile stimulation. The patient generally maintains a patent airway without intervention, adequate spontaneous ventilation, and cardiovascular function. Most interventional pain procedures use local anesthesia alone; moderate sedation or anesthesia may be appropriate in selected cases involving prolonged immobility, painful positioning, or patient-specific safety risks.

    Key Definition

    Moderate sedation or conscious sedation
    TermModerate sedation or conscious sedation
    Level of consciousnessA drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
    Physiologic characteristicsNo interventions are required to maintain a patent airway; spontaneous ventilation is adequate, and cardiovascular function is usually maintained.

    Imaging and Procedure Requirements

    Note

    Check the procedure-specific imaging requirement

    The policy scope includes percutaneous image-guided interventional pain procedures, but it does not specify fluoroscopy or another imaging modality as a universal coverage requirement for moderate sedation.

    • Imaging requirement: Not otherwise specified.
    Note

    Apply imaging guidance by procedure

    Imaging guidance is procedure-dependent for interventional pain procedures. Follow the guidance specified for the individual procedure; imaging is not universal, as the policy also lists procedures performed without imaging guidance.

    • Image-guided examples include spinal injections, neurolytic destruction, neuromodulation or intravertebral procedures, sacroiliac injections, transforaminal epidural injections, and facet injections.
    • The listed procedures also include cervical or thoracic and lumbar or sacral epidural injections without imaging guidance.

    Noncovered Services

    The following services are not covered under this policy: trigger point injections; peripheral joint injections, including knee, shoulder, or wrist injections; other pain management services unless performed with a surgical procedure; and anesthesia or moderate sedation billed with pain management services for a patient 18 years of age or older when no qualifying surgical procedure in the range 10021–69990, other than a pain management procedure, is also present.

    Policy Summary
    PayerPriority Health Medicare
    PolicyModerate Sedation for Interventional Pain Management
    Policy CodePolicy 91632
    Change TypeAdministrative/template updateno material clinical or coding change
    Effective DateJun 1, 2026
    Last ReviewMay 13, 2026
    Next Review DateN/A
    Key ActionReport modifier KX when the medical policy requirements have been met.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCodes and Billing ParametersAuthorization, Documentation, and Billing ActionsClinical BackgroundKey DefinitionImaging and Procedure RequirementsNoncovered Services
    Claim applicationThe range applies to anesthesia and moderate sedation services billed with pain management services for patients 18 years of age or older.
    Documentation Required

    Document Patient-Specific Risk Factors

    Document patient-specific risk factors supporting moderate sedation for the applicable pathway. At least one qualifying factor must be present and documented.

    • Severe anxiety or another severe psychiatric condition or severe cognitive impairment that could place the member’s safety at risk during the planned procedure; severe anxiety must be under active medical management with psychotropic medication and/or cognitive therapy.
    • History of needle phobia reported by the member.
    • History of previous interventional pain management procedures requiring moderate sedation to complete safely.
    • Chronic opioid therapy contributing to sensitivity to pain.
    Billing Rule

    Explain Unlisted Procedure Code 64999

    When billing unlisted procedure code 64999, include explanatory notes with the claim.

    • CPT 64999: Unlisted procedure, nervous system.
    Billing Rule

    Report Modifier KX

    Report modifier KX when the requirements specified in the medical policy have been met.

    Denial Risk

    Watch for Excluded Procedures or Indications

    Anesthesia and moderate sedation for an adult undergoing another interventional pain management procedure is considered not medically necessary for other indications, including the procedures listed below.

    • Trigger point injections.
    • Peripheral joint injections, including knee, shoulder, or wrist injections.
    Denial Risk

    Other Pain Management Services

    Anesthesia and moderate sedation for all other pain management services are not covered unless performed with a surgical procedure.

    Note

    Pediatric Services Outside Policy Scope

    This policy does not apply to children under 18 years of age.

    Denial Risk

    Include a Qualifying Surgical Procedure

    For a patient age 18 or older, anesthesia and moderate sedation services billed with pain management services will be denied unless a qualifying surgical procedure in the range 10021–69990, other than a pain management procedure, is also present.

    • An exception applies when anesthesia services are billed with modifiers indicating severe systemic disease: physical status modifier P3, physical status modifier P4, or monitored anesthesia care modifier G9.