CurrentAmbetter NevadaPolicy NV.CP.MP.158

Ambulatory Surgery Center Optimization

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Defines when elective low-risk surgeries and procedures are appropriate to be performed in an Ambulatory Surgery Center (ASC) and lists clinical contraindications that require care in an inpatient or outpatient hospital setting; applies to providers and members of Ambetter Nevada.

Policy Summary

PayerAmbetter Nevada

PolicyAmbulatory Surgery Center Optimization

Policy CodePolicy NV.CP.MP.158

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionRedirect procedures listed in Table 1 to an ASC when the listed contraindications are not present and the provider has ASC privileges.

SourceLink

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CurrentAmbetter NevadaPolicy NV.CP.MP.158

Ambulatory Surgery Center Optimization

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Policy Summary

PayerAmbetter Nevada

PolicyAmbulatory Surgery Center Optimization

Policy CodePolicy NV.CP.MP.158

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionRedirect procedures listed in Table 1 to an ASC when the listed contraindications are not present and the provider has ASC privileges.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

22codes table

>=3hoperative time threshold

>50BMI contraindication

>8MELD contraindication

Table of CPT codesexample procedures

Ambulatory Surgery Center (ASC) Coverage Criteria

ASC Appropriate Procedures

Covered in ASC when ALL of the following are met

ASC coverage prerequisites: 1) Procedure is elective and low-risk; 2) None of the listed contraindications (items 1-17) are present; 3) Procedure is determined medically appropriate for ASC by nationally recognized clinical decision support tools (e.g., InterQual or MCG); 4) If performed in an inpatient or outpatient hospital setting despite being ASC-appropriate, the service may be considered not provided in the most appropriate care setting and providers will be directed to the ASC when privileges exist.

Derived from policy statements and criteria

Contraindications (Any)

Not appropriate for ASC when ANY of the following are present

Contraindications list: 1) Procedure is emergent or for a life‑threatening situation; 2) BMI > 50; 3) ASA physical status (PS) class 4 or higher; 4) Personal or family history of severe anesthesia complication (e.g., malignant hyperthermia); 5) Severe uncontrolled obstructive sleep apnea; 6) Operative time expected >3 hours and combined operative and recovery time anticipated >23 hours; 7) Expected extensive blood loss or need for special infusion products to correct a coagulation defect (DDAVP is not a blood product and is not a contraindication); 8) Pregnancy when member or provider declines ASC; 9) Uncompensated chronic heart failure (NYHA class III or IV); 10) History of myocardial infarction in the past 6 months; 11) Coronary artery disease with ongoing ischemia requiring ongoing medical management or STENT placement in the last 6 months; 12) Significant uncompensated valvular heart disease; 13) Symptomatic cardiac arrhythmia despite medication; 14) Cardiomyopathy with ejection fraction <30%; 15) Poorly controlled asthma (FEV1 <80% despite medical management); 16) Advanced liver disease (MELD Score >8)

Each listed item alone is sufficient to contraindicate ASC per policy

DDAVP (desmopressin) is explicitly stated in the policy as not a blood product and therefore is not a contraindication to care in an Ambulatory Surgery Center (ASC). This language appears in the list of contraindications where the policy specifies that procedures expected to result in extensive blood loss or that require special infusion products to correct a coagulation defect may preclude ASC care, but clarifies that DDAVP is not considered a blood product and is not a contraindication.

The policy directs that procedures identified as appropriate for an ASC (see Table 1) should be redirected to an ASC when the listed contraindications are absent. If such ASC-appropriate procedures are nonetheless performed in an inpatient or outpatient hospital setting, the service is considered not provided in the most appropriate care setting. Providers requesting or performing these services in a hospital will be directed to the ASC when the requesting physician holds privileges at a qualified ASC capable of providing the procedure.

Codes, Time, and Clinical Thresholds

Table 1: Codes that will be redirected from an outpatient hospital when criteria are metCPT | mixed

19120	Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion
19380	Revision Of Reconstructed Breast
20680	Removal Implant Deep
27792	29806: Surgical Arthroscopy Shoulder Capsulorrhaphy
36558	Insj Tunneled CVC Without Subcutaneous Port/Pump Age 5 Yr/>
36589	Removal Tunneled CVC Without Subcutaneous Port/Pump
41899	Unlisted Procedure Dentoalveolar Structures
43235	Esophagogastroduodenoscopy Transoral Diagnostic
43239	EGD Transoral Biopsy Single/Multiple
45378	Colonoscopy

1–10 of 22

1/3

Operative time and total anticipated time

Operative time thresholdOperative time expected >3 hours

Total anticipated time thresholdCombined operative and recovery time anticipated to be >23 hours

Policy consequenceIf this threshold is met, the procedure is a contraindication to ASC and should be performed in a hospital setting

BMI

BMI thresholdBMI > 50

Contraindication statusBMI > 50 is listed as a contraindication to ASC care

Action

Provider Requirements and Site-of-Care Actions

Prior Authorization

Site-of-care prior authorization / redirection

Procedures identified in the policy's Table 1 (CPT examples) should be redirected to an Ambulatory Surgery Center (ASC) when the listed contraindications are not present. Providers must obtain site-of-care prior authorization or follow the Health Plan's redirection process before scheduling the procedure in an outpatient hospital setting.

Applies when the requesting physician has privileges at a qualified ASC capable of providing the requested procedure.
See Table 1 (policy) for example CPT codes that may be redirected.

Denial Risk

Site-of-care denial risk

Procedures that are medically appropriate for performance in an ASC but are performed in an inpatient or outpatient hospital setting are considered not provided in the most appropriate care setting. Such services may be denied or redirected unless prior authorization or an approved exception is obtained.

Background

Ambulatory Surgery Centers (ASCs) provide outpatient surgical services for elective, low-risk procedures and patients and are recognized as a safe, cost-effective alternative to hospital-based outpatient or inpatient surgery. The policy requires that for a procedure to be covered in an ASC, all of the following must be met: the procedure is elective and low-risk; none of the listed contraindications are present; and a nationally recognized clinical decision support tool (for example, InterQual or MCG) determines the procedure is medically appropriate for ASC care.

Definitions and Clinical Scores

ASA PS class 4 or higher

DefinitionAmerican Society of Anesthesiologist (ASA) physical status (PS) class 4

ContextASA PS class 4 or higher is listed as a contraindication to ASC care in policy

ImplicationPatients meeting ASA PS class 4+ should be managed in a hospital setting

MELD Score

DefinitionModel for End-Stage Liver Disease (MELD) score

Policy thresholdMELD Score > 8 is a contraindication to ASC care

Implication

Policy Summary

PayerAmbetter Nevada

PolicyAmbulatory Surgery Center Optimization

Policy CodePolicy NV.CP.MP.158

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionRedirect procedures listed in Table 1 to an ASC when the listed contraindications are not present and the provider has ASC privileges.

SourceLink

On This Page

Patients with BMI > 50 should be directed to appropriate hospital setting rather than ASC

ASA physical status

ASA classificationASA physical status (PS) class 4 or higher

Contraindication statusASA PS class 4 or higher is listed as a contraindication to ASC care

ActionMembers with ASA PS class 4+ should have procedures performed in a hospital setting

Cardiac: recent MI or stent

Recent myocardial infarctionHistory of myocardial infarction in past 6 months

Recent coronary stentSTENT placement in last 6 months

Contraindication statusEither condition is listed as a contraindication to ASC care

Ejection fraction

Ejection fraction thresholdCardiomyopathy with EF < 30%

Contraindication statusEF < 30% is listed as a contraindication to ASC care

ActionPatients with EF < 30% should be managed in an appropriate hospital setting

Asthma control

Asthma control metricPoorly controlled asthma defined as FEV1 < 80% despite medical management

Contraindication statusPoorly controlled asthma is listed as a contraindication to ASC care

ActionPatients with FEV1 < 80% despite management should not undergo procedures in ASC

Liver disease (MELD)

MELD thresholdMELD Score > 8

Contraindication statusMELD > 8 is listed as a contraindication to ASC care

ActionMembers with MELD > 8 should have procedures in a hospital setting rather than ASC

Providers will be directed to the most appropriate care setting when the requesting physician has ASC privileges and the ASC can provide the procedure.
Performing an ASC-appropriate procedure in a hospital setting without authorization may result in claim denial or payment reprocessing to the appropriate site-of-care reimbursement level.

Documentation Required

Coding and documentation guidance

Reference current CPT coding and professional coding guidance prior to claim submission. Codes included in this policy are for informational purposes only and inclusion or omission does not guarantee coverage. Ensure documentation supports medical necessity and site-of-care decisions per plan requirements.

Verify CPT descriptions and modifiers from the current AMA CPT code set before billing.
Include clinical documentation showing ASC appropriateness (e.g., clinical decision support results, physician privileges at ASC, ASA status, contraindications) with prior authorization requests or claim support.
Codes referenced in policy Table 1 (examples): 19120, 19380, 20680.

Note

(Provider action placeholder)

Calculate MELD; if >8, consider hospital setting for procedure