Clinical UM Guideline

This document addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures.

Note: Please see the following document for additional information on moderate sedation:

• CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation

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.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

For interventional pain management procedures, including but not limited to nerve blocks, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the following criteria have been met:

1. There is documentation that the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure; and
2. The medical condition or procedure must be significant enough to require the need for anesthesia services, including MAC. Such conditions or procedures may include, but are not limited to the following:
   1. Significant medical conditions (ASA physical status 3 or above) that increase risk for complications including cardiac disease, pulmonary disease, and morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m²); or
   2. Sleep apnea; or
   3. History of complications during sedation; or
   4. Severe anxiety, psychiatric conditions, or cognitive impairments that decrease safety during the procedure; or
   5. Spasticity or neurological conditions that decrease safety during the procedure; or
   6. Procedures requiring individuals to remain motionless for a prolonged period of time; or
   7. Procedures requiring individuals to remain in a painful position; or
   8. Individuals under the age of 18.

Note: 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.

Not Medically Necessary:

Anesthesia services for interventional pain management procedures are considered not medically necessary for all other indications.

This document describes clinical studies and expert recommendations, and explains when anesthesia services for interventional pain management procedures are clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Monitored anesthesia care (MAC) is a type of anesthesia service provided by a trained anesthesia professional, such as an anesthesiologist or certified registered nurse anesthetist. During procedures intended to treat a source of pain such as injection of numbing medications, MAC may be used when a person has certain health conditions or when the procedure requires a higher level of monitoring of their health status and level of sedation. MAC includes checking a person's health before the procedure, monitoring breathing and heart function during the procedure, managing sedation, and providing care afterward. While many pain procedures can be performed with local anesthesia or moderate sedation, some people may need MAC to help improve safety and comfort.

What the Studies Show

Interventional pain procedures are used to diagnose or treat pain. Examples include nerve blocks and injections using numbing medications. Many of these procedures can be performed with local anesthesia or moderate sedation. MAC is different because it is provided by a qualified anesthesia professional whose main role is to monitor the person, manage sedation, and respond to complications if they occur. MAC can provide deeper levels of sedation when needed and allows the anesthesia professional to adjust sedation based on the person's condition and the procedure.

Expert recommendations from the American Society of Anesthesiologists (ASA) state that MAC can help support safety and comfort during more difficult procedures or for people with major health concerns. However, the use of sedation and anesthesia should balance potential benefits with possible risks. Deeper sedation can affect breathing, heart function, or airway safety, which is why specially trained anesthesia professionals are required when MAC is used. Many routine pain procedures generally do not require MAC.

When is Monitored Anesthesia Care Clinically Appropriate?

MAC may be clinically appropriate in these situations:

• There is documentation showing that a qualified anesthesia professional is needed in addition to the doctor performing the procedure; and
• The person's medical condition or the procedure is significant enough to require anesthesia services, such as:
  • Serious medical conditions that increase the risk of complications, including significant heart disease, lung disease, or severe obesity; or
  • Sleep apnea; or
  • A history of problems during previous sedation; or
  • Severe anxiety, mental health conditions, or thinking and memory problems that could reduce safety during the procedure; or
  • Muscle stiffness, muscle spasms, or neurologic conditions that could reduce safety during the procedure; or
  • Procedures that require a person to stay completely still for a long period of time; or
  • Procedures that require a person to remain in a painful position; or
  • Age younger than 18 years.

When is this not Clinically Appropriate?

Many interventional pain procedures can be safely performed using local anesthesia or moderate sedation instead of MAC. Expert recommendations note that anesthesia services should be used when the benefits outweigh the risks and when a higher level of monitoring or sedation is needed.

MAC is not clinically appropriate in scenarios other than those listed above.

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The following codes for treatments and procedures applicable to this guideline 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:
For the following anesthesia procedures related to pain management services

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:

Summary

Interventional pain management procedures are commonly performed using local anesthesia or moderate sedation. However, for more complex procedures or for individuals with significant medical conditions, monitored anesthesia care (MAC) may be medically appropriate. MAC is a distinct anesthetic service provided by qualified anesthesia professionals and includes comprehensive care such as preprocedural assessment, management of sedation levels, including potential escalation to general anesthesia and postprocedural support. According to the American Society of Anesthesiologists (ASA, 2021), MAC is recommended and ensures the safety, comfort, and adaptability of individuals during more invasive or prolonged procedures, particularly when the condition or procedure warrant a higher level of anesthetic care.

Discussion

Interventional pain management procedures are typically performed to diagnose or treat chronic pain conditions. These procedures are often performed without the use of sedation or with moderate sedation administered or overseen by the practitioner performing the procedure. However, when the procedure is complex or when the individual has significant medical conditions, a second practitioner may be needed to provide MAC. MAC is an anesthetic service for a diagnostic or therapeutic procedure in which a qualified anesthesia practitioner (for example, an anesthesiologist or nurse anesthetist) provides sedation, monitors vital functions, and treats complications.

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

Monitored anesthesia care is 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.

Monitored Anesthesia Care can be distinguished from Moderate Sedation in several ways. Proceduralists providing moderate sedation may have their attention divided between their primary focus, the procedure, and secondary focus, patient sedation. Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s respiratory or cardiovascular functions or ability to maintain airway integrity. A provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC. These components of MAC are unique aspects of an anesthesia service that are not part of Moderate Sedation. In addition, MAC includes an array of post-procedure responsibilities beyond the expectations of practitioners providing Moderate Sedation, including assuring a return to baseline consciousness, relief of pain, management of adverse physiological responses or side effects from medications administered during the procedure, as well as the diagnosis and treatment of co-existing medical problems.

Monitored Anesthesia Care allows for the safe administration of a depth of sedation in excess of that provided during Moderate Sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during a procedure provides maximal flexibility in matching sedation level to a patient’s needs and procedural requirements. In situations where the procedure is more invasive, or when the patient is especially fragile, optimizing sedation level while maintaining cardiopulmonary function is necessary to achieve ideal procedural conditions.

In summary, MAC is an anesthesia service that is clearly distinct from Moderate Sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.

The ASA, in a Statement on Anesthetic Care During Interventional Pain Procedures for Adults (ASA, 2021), states the following:

Use of sedation and/or anesthesia during the performance of pain procedures requires balancing the needs of the patient with the potential risks. The Committee recognizes the provision of procedural sedation or anesthesia as a separate and distinct service from the pain procedure, thus requiring specific training and credentialing as detailed in the ASA “Statement on Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals.” When sedation is provided during the performance of a pain procedure, it should allow the patient to be responsive during critical portions of the procedure, e.g., to report potential procedure-related paresthesia, acute changes in pain intensity or function, or potential toxicities.

Interventional pain procedures generally only require local anesthesia; however, patients may elect to also receive supplemental sedation. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can prescribe minimal sedation/analgesia (anxiolysis) or moderate (conscious) sedation as part of the procedure. For a limited number of patients, an anesthesia care team may be required (see ASA “Statement on the Anesthesia Care Team”). Examples of procedures that typically do not require moderate sedation or an anesthesia care team include but are not limited to epidural steroid injections; epidural blood patch; trigger point injections; shoulder, hip, sacroiliac, facet and knee joint injections; medial branch nerve blocks; and peripheral nerve blocks. 

Significant patient anxiety and/or medical comorbidities may be an indication for moderate (conscious) sedation or anesthesia care team services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require moderate sedation or anesthesia care team services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral, and hypogastric); chemical or radiofrequency ablation; percutaneous discectomy; vertebral augmentation procedures; trial spinal cord stimulator lead placement; permanent spinal cord stimulator generator and lead implantation; and intrathecal pump implantation.

Anesthesia services are not the same as moderate (conscious) sedation. For more information, see the ASA Statements “Distinguishing Monitored Anesthesia Care (‘MAC’) from Moderate Sedation/Analgesia (Conscious Sedation)” and “Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia.”

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Anesthesiologists (ASA). Statements and practice parameters. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters. Accessed on July 30, 2026.

• ASA physical status classification system. Last amended December 13, 2020.
• Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Committee of origin: Quality Management and Departmental Administration. Last amended October 23, 2024.
• 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. Last amended March 2018.
• Statement on anesthetic care during interventional pain procedures for adults. Last amended October 13, 2021.
• Statement on distinguishing monitored anesthesia care ("MAC") from moderate sedation/analgesia (conscious sedation). Original approval October 18, 2023.
• Statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Last amended October 13, 2021.
• Statement on granting privileges for deep sedation to non anesthesiologist physicians. Last amended October 26, 2022.
• Statement on regional anesthesia. Last amended October 26, 2022.
• Statement on the medical necessity of anesthesiology services. Last amended October 18, 2023.

1. National Institute of Health. NIH Pain Consortium. Last reviewed May 16, 2025. Available at: https://www.ninds.nih.gov/current-research/trans-agency-activities/pain-consortium. Accessed on July 30, 2026.

Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)

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

(ASA Physical Status Classification System, 2020)

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