Clinical UM Guideline

This document addresses the medical necessity of anesthesia services. Anesthesia services include all services associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation (“conscious sedation”), and local infiltration or topical application. This document does not address anesthesia services performed during gastrointestinal endoscopic procedures.

Note: Please see the following documents for additional information:

• CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
• CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
• CG-MED-65 Manipulation Under Anesthesia
• CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures

Note: This document does not address whether or not reimbursement is provided for the anesthesia service and is not intended to explain the billing and reimbursement of anesthesia.

Medically Necessary:

General Anesthesia or Regional Anesthesia
Administration of general or regional anesthesia is considered medically necessary when both of the following criteria are met:

1. The services are provided by an individual other than the attending physician performing the procedure; and
2. Alternative types of anesthesia, sedation, or analgesia are not appropriate.

If general or regional anesthesia is requested for a procedure typically not requiring either of these levels of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.

Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:

1. MAC is requested by the attending physician; and
2. The services are provided by an individual other than the attending physician performing the procedure; and
3. Qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists) administering monitored anesthesia care are continuously present to monitor the individual and provide anesthesia care; and
4. The individual's medical condition requires medical direction or supervision of the anesthetic to ensure control of the sedation, medication, and airway, and to prevent sudden changes in condition from disrupting the procedure and placing the individual at risk; and
5. Constant monitoring of the individual’s vital signs is provided to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the procedure may become more extensive, or result in unforeseen complications, requires comprehensive monitoring or anesthetic intervention; and
6. Appropriate documentation is available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.

Anesthesia Services including MAC for Surgical Procedures
For surgical procedures which do not usually require anesthesia services, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented. The medical condition must be significant enough to impact the need to provide anesthesia services including MAC. Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Moderate (“Conscious”) Sedation
Moderate sedation (“conscious sedation”) ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Local Anesthesia
The administration of local anesthesia is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Standby Anesthesia Services
Standby anesthesia service is when the anesthesiologist would be immediately available if a clinical need should arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia.

Not Medically Necessary:

Anesthesia services are considered not medically necessary for all other indications.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Note:  The following list of anesthesia service modifiers is for informational purposes:

Anesthesia services are provided by or under the supervision of a physician. Services consist of the administration of an anesthetic agent in various types of anesthesia.

Types of Anesthesia and Anesthesia Services

Anesthesia Service by the Surgeon: Anesthesia services personally furnished by the physician performing the surgical, therapeutic or diagnostic procedure are considered an integral component of the primary procedure. This may include local injections, regional blocks, and intravenous medication. General anesthesia administered and monitored by the surgeon is not considered medically appropriate.

Balanced Anesthesia: Anesthesia that uses a combination of drugs, each in an amount sufficient to produce its major or desired effect to the optimum degree and keep its undesirable or unnecessary effects to a minimum.

Bier Block/Intravenous Regional Anesthesia (IVRA): Regional anesthesia produced by intravenous injection, used for surgical procedures on the arm below the elbow or the leg below the knee; performed in a bloodless field maintained by a pneumatic tourniquet that also prevents the anesthetic from entering the systemic circulation.

Brachial Plexus Block/Brachial Plexus Anesthesia: Regional anesthesia of the shoulder, arm, and hand by injection of a local anesthetic into the brachial plexus.

Caudal Block/Caudal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the caudal or sacral canal.

Epidural Block/Epidural Anesthesia: Regional anesthesia produced by injection of the anesthetic agent between the vertebral spines and beneath the ligamentum flavum into the epidural space.

General Anesthesia: A reversible state of unconsciousness and the inability to perceive pain, produced by anesthetic agents, with absence of pain sensation over the entire body and a greater or lesser degree of muscular relaxation; the drugs producing this state can be administered by inhalation, intravenously, intramuscularly, rectally, or via the gastrointestinal tract.

Inhalation Anesthesia: Anesthesia produced by the inhalation of vapors of a volatile liquid or gaseous anesthetic agent.

Intercostal Block/Intercostal Anesthesia: Anesthesia produced by blocking intercostal nerves with a local anesthetic.

Intranasal Anesthesia: Local anesthesia produced by insertion into the nasal fossae of pledgets soaked in a solution of an anesthetic agent which is effective after topical application, or by insufflation of a mixture of anesthetic gases or vapors through a tube introduced into the nose.

Intraoral Anesthesia: Anesthesia produced within the oral cavity by injection, spray, pressure, etc.

Intrathecal Anesthesia: Anesthesia produced by injection of an anesthetic solution into the subarachnoid space.

Intravenous Anesthesia/Intravenous Sedation (IV Sedation): Anesthesia produced by introduction of an anesthetic agent into a vein.

Local Anesthesia: Anesthesia confined to one area of the body.

Moderate (“Conscious”) Sedation: Involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the individual's ability to respond to stimulation. Moderate (“conscious”) sedation is administered by the surgeon or physician performing the procedure or an independent trained practitioner for the purpose of assisting the physician in monitoring the individual's level of consciousness and physiological status. It includes pre- and post-sedation evaluations, administration of the sedation and monitoring of the cardiorespiratory function. Cardiorespiratory functions monitored include heart rate, blood pressure and oxygen level.

Monitored Anesthesia Care (MAC): MAC was developed in response to the shift to providing more surgical and diagnostic services in an ambulatory, outpatient or office setting without the use of the traditional general anesthetic. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain consciousness altering drugs. This type of anesthesia is referred to as MAC if directly provided by anesthesia personnel. Based on the American Society of Anesthesiologists' (ASA) standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists). These individuals must be continuously present to monitor and provide anesthesia care.

As described by the ASA’s Statement on Distinguishing Monitored Anesthesia Care ("MAC") from Moderate Sedation/Analgesia (Conscious Sedation) (2023):

The American Society of Anesthesiologists has defined Monitored Anesthesia Care (MAC) as a specific anesthesia service performed by a qualified (trained) anesthesia provider, for a diagnostic or therapeutic procedure. Indications for MAC include, but are not limited to, the nature of the procedure, the patient’s clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic). Monitored Anesthesia Care includes all aspects of anesthesia care – a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service.

During MAC, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

• Preprocedural assessment and management of patient comorbidity and periprocedural risk
• Diagnosis and treatment of clinical problems that occur during the procedure
• Support of vital functions inclusive of hemodynamic stability, airway management, and appropriate management of the procedure induced pathologic changes as they affect the patient’s coexisting morbidities
• Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary for patient safety
• Psychological support and physical comfort
• Provision of other medical services as needed to complete the procedure safely
• Postoperative medical and pain management

MAC may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesia provider of monitored anesthesia care must be prepared to manage all levels of sedation up to and including general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of the procedure and patient positioning. Please also refer to ASA’s Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.

Regional Anesthesia: Anesthesia that involves the use of local anesthetic solutions(s) to produce circumscribed areas of loss of sensation. This includes spinal, epidural, nerve, field and extremity blocks. Spinal and epidural anesthesia is produced by injection of local anesthetic solution near the spinal canal, which interrupts sensation from the legs or abdomen.

Sacral Block/Sacral Anesthesia: Anesthesia produced by injection of a local anesthetic into the extradural space of the sacral canal.

Saddle Block Anesthesia: A type of sacral anesthesia produced in a region corresponding roughly with the area of the buttocks, perineum, and inner aspects of the thighs, by introducing the anesthetic agent low in the dural sac.

Spinal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord.

Standby Anesthesia: Anesthesia standby occurs when the anesthesiologist, or the CRNA, is available in the facility in the event he or she is needed for a procedure that requires anesthesia (e.g., available in the facility in case of obstetric complications - breech presentation, twins, and trial of instrumental delivery), but is not physically present or providing services. Standby anesthesia is not direct care (for instance, it is a standby service without direct hands-on contact).

Topical Anesthesia: Anesthesia produced by application of a local anesthetic directly to the area involved.

American Society of Anesthesiologists Levels of Sedation/Analgesia (ASA, 2019)

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients 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 maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients 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 impaired.

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia.

*Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.” Indications for monitored anesthesia care include “the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic.”

**Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

***Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Anesthesiologists. ASA physical status classification system. Last amended December 13, 2020. For additional information visit the ASA website: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system. Accessed on April 10, 2024.
2. American Society of Anesthesiologists. Statement on continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Last amended October 23, 2019. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia. Accessed on April 10, 2024.
3. American Society of Anesthesiologists. Statement on distinguishing monitored anesthesia care ("MAC") from moderate sedation/analgesia (Conscious Sedation). October 18, 2023. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-distinguishing-monitored-anesthesia-care-from-moderate-sedation-analgesia. Accessed on April 10, 2024.
4. American Society of Anesthesiologists. Statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Last amended October 26, 2016, reaffirmed October 13, 2021. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-granting-privileges-for-administration-of-moderate-sedation-to-practitioners-who-are-not-anesthesia-professionals. Accessed on April 10, 2024.
5. American Society of Anesthesiologists. Statement on regional anesthesia. Last amended October 26, 2022. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-regional-anesthesia. Accessed on April 10, 2024.
6. American Society of Anesthesiologists. Statement on granting privileges for deep sedation to non anesthesiologist physicians. Last amended October 26, 2022. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-granting-privileges-for-deep-sedation-to-non-anesthesiologist-physicians. Accessed on April 10, 2024.
7. 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. For additional information visit the ASA website: https://pubs.asahq.org/anesthesiology/article/128/3/437/18818/Practice-Guidelines-for-Moderate-Procedural?_ga=2.214982231.195750751.1631283750-1852758448.1630089184. Accessed on April 10, 2024.

Anesthesia Services
Conscious Sedation
General Anesthesia
Moderate Sedation
Monitored Anesthesia Care (MAC)
Regional Anesthesia

American Society of Anesthesiology Physical Status Classifications:

ASA I    A normal healthy patient

ASA II   A patient with mild systemic disease

ASA III  A patient with severe systemic disease

ASA IV  A patient with severe systemic disease that is a constant threat to life

ASA V   A moribund patient who is not expected to survive without the operation

ASA VI  A declared brain-dead patient whose organs are being removed for donor purposes

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.