Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious 
sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or 
medial branch blocks and are not routinely reimbursable. Individual consideration may be given on 
redetermination (appeal) for payment in rare unique circumstances if the medical necessity of sedation is 
unequivocal and clearly documented in the medical record.  
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
The presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The 
medical condition must be significant enough to impact on the need to provide MAC such as the patient being 
on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily 
sufficient. 
1. All documentation must be maintained in the patient's medical record and made available to the contractor 
upon request. 
2. Every page of the record must be legible and include appropriate patient identification information (e.g., 
complete name, dates of service[s]). The documentation must include the legible signature of the physician or 
non-physician practitioner responsible for and providing the care to the patient. 
3.The medical record documentation must support the medical necessity of the services as stated in this policy. 
4. Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the 
patient's condition that requires the appropriate anesthesia; indications the procedure performed was deep, 
complex, complicated or markedly invasive). 
5. The medical record should include a pre-anesthesia evaluation including a history and physical exam. 
6. The medical record should include evidence of continuous monitoring of the patient's oxygenation, 
ventilation, circulation and temperature. 
7. The medical record should include a post-anesthesia evaluation of the patient including any unusual events 
or complications and the patient's status on discharge. 
You can find this information in Local Coverage Determination (LCD): Monitored Anesthesia Care (L35049). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.