Health insurance company Cigna recently announced new medical coverage policies for the use of anesthesia services for interventional pain management procedures. The policies, which apply to procedures like diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures, will become effective February 15, 2020.
According to Cigna, the new policy guidelines “are based on published practice parameters, recommendations, and professional society/organization consensus guidelines.” Specifically, they outline the specific circumstances when moderate sedation, also known as conscious sedation, and monitored anesthesia care, a service which may include varying levels of sedation, will be covered under their health insurance plans for interventional pain management.
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:
- 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) OR
- The presence of one of the following–severe anxiety, and/or other psychiatric conditions, or cognitive impairments–when 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, or sacroiliac joint injection.
Moderate sedation for an adult undergoing an interventional pain management procedure is considered not medically necessary for ANY other indication, including the following:
- Trigger point injection
- Peripheral joint injection (e.g., knee, shoulder, wrist)
Monitored Anesthesia Care
Monitored anesthesia care (MAC) for an adult undergoing an interventional pain management procedure is considered medically necessary when EITHER of the following criteria are met:
- 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), OR
- One 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, or sacroiliac joint injection–and any of the following are present: 1.) increased risk for complications due to ASA physical status III or above; 2.) any of the following comorbidities that increase risk for complications: severe cardiac disease and/or pulmonary disease (e.g., severe hypotension [systolic <90mm hg, major cardiac dysfunction), documented sleep apnea, morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m2), chronic renal failure [GRF < 60ml/min for more than 3 months or stage 3A], chronic liver disease [end stage liver disease score >10], age > 70 years; 3.) severe anxiety, and/or other psychiatric conditions, or cognitive impairments; 4.) spasticity or movement disorder (e.g., cerebral palsy, dystonia, brain injury, stroke); 5.) risk of airway obstruction due to anatomical variation (e.g., neck mass, jaw abnormality, abnormality of oral cavity, neck tumor, neck edema, tracheal deviation); 6.) history of or anticipated intolerance to monitored sedation (e.g., chronic opioid or benzodiazepine use); or 7.) history of drug or alcohol abuse.
MAC for an adult undergoing an interventional pain management procedure is considered not medically necessary for ANY other indication, including the following:
- Trigger point injection
- Peripheral joint injection (e.g., knee, shoulder, wrist)
For more information about Cigna’s new policy, review their Medical Coverage Policy #0551: Anesthesia Services for Interventional Pain Management Procedures in an Adult. Also note that the policy includes specific CPT, HCPCS, and ICD-10 codes that must be used on claims to indicate medical necessity and to receive proper reimbursement.
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