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Anesthesia Services for Interventional Pain Management ...

Page 1 of 22 Medical Coverage Policy: 0551 Medical Coverage Policy Effective Date .. 2/15/2021 Next Review Date .. 2/15/2022 Coverage Policy Number .. 0551 Anesthesia Services for Interventional pain Management Procedures in an Adult Table of Contents Overview .. 1 Coverage Policy .. 2 General Background .. 3 Medicare Coverage Determinations .. 5 Coding/Billing Information .. 5 References .. 21 Related Coverage Resources INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review Services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based.

• 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 a intrathecal infusion device . Page 2 of 22 ...

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