The Office of Inspector General (OIG) recently released a Medicare Part B audit titled “Medicare Could Have Saved an Estimated $17.7 Million if CMS’s Oversight Had Prevented At-Risk Payments for Anesthesia Administered During Spinal Pain Management Procedures” (SPM). Per the OIG report, if Medicare oversight had been adequate to prevent or detect at-risk payments for anesthesia administered during selected SPM procedures, Medicare could have saved an estimated $17.7 million for the audit period of dates of service of May 2021 through August 2023. Medicare paid for anesthesia services that providers do not need to administer, except in rare circumstances, per the Medicare Administrative Contractor (MAC) Local Coverage Decision (LCD) policies.1

The procedures of focus in this audit included facet-joint interventions and denervation, epidural steroid injections, and sacroiliac joint injections. Anesthesia was administered during approximately 18 percent of 3.9 million sessions of these selected SPM procedures, and MACs denied payment less than 1 percent of the time. The OIG deemed general anesthesia, monitored anesthesia care, and moderate sedation as high risk when reported on the same date of service (DOS) as these SPM procedures.

Active LCD policies from MACs document their anesthesia medical necessity requirements in encounters involving SPM procedures. For example, the MAC CGS Administrators’ policy L38773 titled “Facet Joint Interventions for Pain Management” cites in the context of facet joint injections, the “routine use of moderate or deep sedation, general anesthesia, and monitored anesthesia care is not considered medically reasonable and necessary”.2 The MAC WPS policy L38841 cites the Spine Intervention Society Factfinder when warning against “the default use of sedation is not associated with clear health/outcome benefits and [is] associated with rare but serious increased risk.”3 In the event the particulars of a specific interventional pain procedure support the need for such anesthesia, CMS expects case specific supportive reasons to be documented in that medical record. In this audit, OIG contends that Medicare frequently did not practice necessary oversight on SPM encounters involving anesthesia usage prior to remitting payment; they did not routinely check that such anesthesia was necessary with these cases.

Protect your health plan’s resources. Do not pay for inappropriate anesthesia payments involving SPM procedures. Context4 Healthcare offers Fraud, Waste and Abuse (FWA) edits that detect at-risk spinal pain management procedures submitted on same DOS as at-risk anesthesia codes. When detected, our user receives an FWA warning message recommending review of the related medical records for documentation that supports the use of the anesthesia reported. C4H recommends our users routinely pull a sample of such medical records and audit them as part of their FWA action plan. Additionally, we recommend our health plan clients clearly document their anesthesia policy with SPM procedures, including tailored allowances that suit their plan.

Context offers a series of FWA edits that flag current FWA schemes as identified by the NHCAA. Additionally, we offer FWA reports which health plans can run on individual codes, claims batches, specific providers, etc. that assist our users in isolating atypical patterns in their data.

Our suite of FWA tools can provide your plan with an effective Payment Integrity solution. Read more about the solutions we offer here: https://www.context4healthcare.com/solutions/medical-payment-integrity/

References:

  1. https://oig.hhs.gov/reports/all/2025/medicare-could-have-saved-an-estimated-177-million-if-cmss-oversight-had-prevented-at-risk-payments-for-anesthesia-administered-during-spinal-pain-management-procedures/
  2.  CGS Administrators LCD Policy L38773:  https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38773&ver=26&bc=0
  3. WPS LCD Policy  L38841:  https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38841&ver=16&bc=0