Does G9654 require prior authorization?

No, G9654 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for G9654?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`G9654`, Monitored anesthesia care (mac)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation of patient's age (≥ 18 years) on date of service.
Documentation of the interventional pain procedure (procedure note and appropriate CPT/HCPCS code) demonstrating the procedure is one of those covered by this policy when used to justify sedation/MAC (e.g., epidural steroid injection, epidural blood patch, facet joint injection, peripheral/spinal nerve root block, sacroiliac joint injection, or procedures requiring prolonged immobility/painful position such as radiofrequency ablation, spinal cord stimulator implantation, intrathecal device implantation).

Clinical documentation supporting the specific rationale for moderate sedation or MAC: either (a) objective documentation that the procedure requires the patient to remain motionless for a prolonged period or remain in a painful position, or (b) for the procedure-plus-risk pathway, documentation that the procedure is one of the listed procedures AND documentation of the specific risk factor(s)/comorbidity(ies) that justify MAC (see list of comorbidities).

If relying on severe anxiety as the justification, documentation that severe anxiety is under active medical management (e.g., current psychotropic medication, cognitive therapy notes) or documentation of other severe psychiatric conditions or severe cognitive impairment that would risk patient safety during the procedure.

Documentation of ASA physical status classification when used to justify MAC (e.g., ASA III or higher) or other pre-procedural anesthesia risk assessment.

Objective evidence for listed comorbidities as applicable: documented sleep apnea diagnosis, BMI (to document morbid obesity ≥ 40 kg/m2 or relevant Z68 code), eGFR and chronicity to document chronic renal failure (eGFR < 60 ml/min/1.73 m2 for > 3 months or stage 3A+), MELD score for chronic liver disease if applicable, age documentation if > 70 years.

Key Coverage Criteria

Moderate sedation (age 18 or over) is medically necessary when the interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (examples: sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).
Moderate sedation (age 18 or over) is medically necessary when BOTH of the following are met: (a) the procedure being performed is ANY of: epidural steroid injection, epidural blood patch, facet joint injection, peripheral and/or spinal nerve root block, sacroiliac joint injection; AND (b) 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 [...]
Monitored anesthesia care (MAC), including use of general anesthesia (intravenous anesthetic without a secured airway), (age 18 or over) is medically necessary when the interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (examples: sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).
Monitored anesthesia care (MAC) (age 18 or over) is medically necessary when BOTH of the following are met: (a) the procedure being performed is ANY of: epidural steroid injection, epidural blood patch, facet joint injection, peripheral and/or spinal nerve root block, sacroiliac joint injection; AND (b) presence of ANY of the following risk factors/comorbidities that increase risk for complications: ASA physical status III or above; severe cardiac disease and/or pulmonary disease (e.g., severe h [...]
Interventional pain management procedures (general scope covered by this policy for adults) include: trigger point injections; epidural steroid injection; epidural blood patch; facet joint injection; peripheral and/or spinal nerve root block; sacroiliac and other joint injection (e.g., knee, shoulder, hip); radiofrequency ablation; implantation of spinal cord stimulator; implantation of an intrathecal infusion device. [...]
Billing/coding: Moderate sedation CPT codes (99152, 99153, 99156, 99157) are considered medically necessary when moderate sedation criteria are met; MAC/anesthesia CPT/HCPCS codes (e.g., 01937-01942, 01991-01992, G9654) are considered medically necessary when MAC criteria are met.

1 Active Policy

CIGNA-0551, Anesthesia Services for Interventional Pain Management Procedures in an Adult

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G9654, Monitored anesthesia care (mac)