Wiki Anesthesia denial 01939-01942

[whitey86]

01939-01942 are being denied by MCR, UHC Commercial and Peoples Health no matter what P1-P4. The main procedures that we are doing are RFA's 64633-64636, Implants and Explants of SCS, vertebroplasty/kyphoplasty and sacroplasty. The majority of our patient's anesthesia dx is F41.8 and F41.9 (MCR LCD A57361). Even though the dx code is on the LCD when we add it the claim will get paid but come back and recoup. When we don't put the anesthesia dx code it denies. UHC and Peoples Health, I call for denials verification reason and I am referred back to MCR A57361. Documentation looks like this. Example of coding: 01940 QZ, QS, P2 Modifier G8 does get added for implants and GA is added when the pt signs an ABN. I'm not sure how else to code the claims. They have already stopped paying anesthesia for ESI's, DMBB's, Transforaminal's.


I'm at a loss.

 

[jkyles]

Unfortunately anxiety alone isn't covered for anesthesia. From Novitas' LCD for FJI: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34892&ver=123

The use of Moderate Sedation for RFA or cyst rupture/aspiration will be considered in individual cases with documentation of medical necessity such as a longstanding well-documented history of inability to cooperate, medical conditions that would prohibit performance of the procedure, or inability to remain motionless. Patient anxiety or preference alone is not sufficient justification. Routine use of Moderate Sedation or Monitored Anesthesia Care (MAC) or use of General Anesthesia or Deep Sedation for RFA is not considered reasonable and necessary.

The other issue is the note seems to treat MAC and moderate sedation as the same thing. Moderate sedation is reported with the 9915- codes, not an anesthesia code. But in this scenario it isn't an option. In addition, if anesthesia provider does perform MAC that would otherwise be covered, such as for a patient who has a movement disorder, the mention of moderate sedation is going to get a denial.

Finally, when does the patient get the ABN? Based on the note, the conversation about the risks started after someone started the IV and there was additional conversation after the patient was brought to the OR. The ABN conversation must happen and the patient make their decision before the procedure begins.

 

[whitey86]

Unfortunately anxiety alone isn't covered for anesthesia. From Novitas' LCD for FJI: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34892&ver=123


The other issue is the note seems to treat MAC and moderate sedation as the same thing. Moderate sedation is reported with the 9915- codes, not an anesthesia code. But in this scenario it isn't an option. In addition, if anesthesia provider does perform MAC that would otherwise be covered, such as for a patient who has a movement disorder, the mention of moderate sedation is going to get a denial.

Finally, when does the patient get the ABN? Based on the note, the conversation about the risks started after someone started the IV and there was additional conversation after the patient was brought to the OR. The ABN conversation must happen and the patient make their decision before the procedure begins.

The patient receives the ABN at check in.

 

[missyah20]

If the patient is being provided Monitored Anesthesia Care for these procedures then these anesthesia codes 01939/01940, 01941/01942, 00300, etc do fall under the Novitas MAC LCD L35049 and Billing and Coding Article A57361. I did reach out to Novitas to clarify which LCD takes precedence in these instances since the surgical LCDs have restrictive language in regards to administration of anesthesia however the MAC LCD includes the anesthesia codes that cover those same procedures. Below is there response/non-response, but to me signals that the LCD that governs is whatever procedure your provider is performing and in this case since they are not performing the procedure itself it would be the MAC LCD.

With Medicare Advantage insurances I link any secondary diagnosis that support per the LCD along with the primary diagnosis on the claim. I would also take a look at the patients H&P and see if there is anything additional that may support per the LCD and Billing & Coding article to help bolster medical necessity for the anesthesia.

CMS Response:
This is in response to your inquiry received as of February 19, 2026 requesting clarification of which Local Coverage Determination (LCD) governs coverage when Monitored Anesthesia Care (MAC) is provided in conjunction with certain interventional pain procedures.

Based on review of the Novitas’ LCDs (Facet Joint Interventions for Pain Management (L34892),Epidural Steroid Injections for Pain Management (L36920), and Monitored Anesthesia Care (L35049) ) if the provider is performing an interventional pain procedure they should refer primarily to the LCD which includes guidelines regarding the procedure being performed on the patient. Please note, if a claim denial is received based on the LCD’s guidance, providers have appeal rights and should include supportive language from the LCD when submitting an appeal.

Ultimately it is the provider’s responsibility to do what is in the best interest of the patient and their medical practice as well as not delay medically reasonable and necessary care. If a service is denied, providers and patients will also have the right to a claim redetermination (appeal) if a claim(s) are denied.