Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57361 (Billing and Coding: Monitored Anesthesia Care) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57361: Billing and Coding: Monitored Anesthesia Care (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 2006
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 47
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A40.3 | — |
| A40.9 | — |
| A41.01 | — |
| A41.02 | — |
| A41.1 | — |
| A41.2 | — |
| A41.3 | — |
| A41.4 | — |
| A41.50 | — |
| A41.51 | — |
| A41.52 | — |
| A41.53 | — |
| A41.54 | — |
| A41.59 | — |
| A41.89 | — |
| A41.9 | — |
| E00.0 | — |
| E00.1 | — |
| E00.2 | — |
| E00.9 | — |
| E01.8 | — |
| E02 | Subclinical iodine-deficiency hypothyroidism |
| E03.0 | — |
| E03.1 | — |
Procedure codes: 00100, 00124, 00148, 00160, 00164, 00300, 00322, 00400, 00410, 00454, 00520, 00522, 00524, 00530, 00532, 00635, 00640, 00702, 00731, 00732, 00842, 00920, 00921, 01130, 01380, 01420, 01490, 01680, 01730, 01780, 01782, 01820, 01829, 01860, 01916, 01920, 01922, 01930, 01937, 01938 and 7 more in the article.
Coverage indications, limitations and medical necessity
Notice: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
• In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.
• During MAC, the patient’s oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.
• Please see CMS IOM Publication 100-04, Medicare Claims Processing Manual , Chapter 12, Sections 50 and 140.3 for CMS requirements for this type of anesthesia.
• Anesthesia procedures listed in the “CPT/HCPCS Codes” section of the related Local Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361), are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, MAC provided by anesthesia personnel may be reasonable and necessary for procedures that are generally provided by the attending surgeon if certain conditions or situations are present. In these situations, MAC may be necessary for these active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. Refer to the related billing and coding article for diagnoses that support the use of MAC in these situations. Special conditions or criteria must be supported by documentation in the medical record.
• The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.
• For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.
• 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.
Summary of evidence (opening)
N/A
The contractor cites 10 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2019-10-17
- Last reviewed by the contractor
- 2018-02-27
- MCD version
- 58
- Derived from
- L32628
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L35049 cover?
Notice: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L35049 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L35049?
The companion billing and coding article A57361 lists 2,006 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L35049?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.