RetiredCapital BluecrossPolicy MP 1.154

Procedures Completed in an Ambulatory Surgery Center Using General or Regional Anesthesia (Retired 1/1/2026)

Defines Capital Blue Cross clinical criteria to determine appropriateness of performing non-emergent outpatient procedures requiring general or regional anesthesia in an Ambulatory Surgery Center (ASC). Specifies required preoperative assessment, acceptable ASA classes, exclusions, and considerations for medically optimized comorbid conditions. Policy retired effective 2026-01-01.

Policy Summary

PayerCapital Bluecross

PolicyProcedures Completed in an Ambulatory Surgery Center Using General or Regional Anesthesia (Retired 1/1/2026)

Policy CodePolicy MP 1.154

Change TypeRetired

Effective DateJan 1, 2026

Next Review Date

Key ActionDocument completion of a preoperative risk assessment including procedure considerations, past health history, cardiac risk assessment (ECG when indicated), and postoperative transportation/caregiver availability prior to the planned procedure.

SourceLink

POLICY UPDATE CHANGES

Policy retired.

Consensus reviews with no change to policy statements on multiple prior dates

I–IIIAllowed ASA classes

>80Age exclusion

>40BMI exclusion

Coverage Summary

Status: RETIRED. Policy retired effective 2026-01-01.

Surface thresholds

Age exclusion> 80 years

BMI exclusion> 40 kg/m2

BMI consideration> 35 kg/m2

Recent embolic event windowwithin 90 days

Recent cardiac event windowPCI/MI/cardiac surgery within 90 days

End-stage renal disease thresholdeGFR < 60 cc/min

Chronic renal disease considerationcreatinine clearance < 60 cc/min

Medical-Necessity Criteria

Appropriateness Criteria for ASC with General or Regional Anesthesia (Medically Necessary)

Medically necessary non-emergent/non-life-threatening outpatient procedures anticipated to require general or regional anesthesia may be appropriate in an ASC when ALL of the following are met:

ALL of the following

Preoperative risk assessment is completed at any appropriate time prior to the planned procedure to include consideration of the procedure to be completed, past health history, cardiac risk assessment (including an electrocardiogram when indicated), and taking into account postoperative transportation and caregiver availability
Document completion of preoperative risk assessment per provider actions
Intended patient has independent functional status with adequate support available in the home during recovery
ASA Physical Classification Score of I, II and III who have been medically optimized (see policy guidelines)ASA I-III

Provider Actions & Operational Impact

Documentation Required

Preoperative risk assessment required

Document completion of a preoperative risk assessment including consideration of the planned procedure, past health history, cardiac risk assessment (electrocardiogram when indicated), and postoperative transportation and caregiver availability prior to the planned procedure.

Documentation Required

ASA classification documented

Document the patient's ASA Physical Classification Score. ASA I, II, and III are acceptable if the patient is medically optimized. ASA definitions are provided in the policy for reference (ASA I: a normal healthy patient; ASA II: mild systemic disease without substantive functional limitations; ASA III: severe systemic disease with substantive functional limitations).

Coding

Specific coding applicabilitymixed

No codes listed

Background & Definitions

Policy emphasizes completion of a preoperative assessment to identify and optimize comorbidities prior to ambulatory surgery, including consideration of the planned procedure, anticipated blood loss and pain control, procedure duration and postoperative care needs, and ensuring postoperative transportation and caregiver availability.

Cardiovascular risk stratification is recommended for all patients scheduled for elective noncardiac surgery and should include history and physical examination (and electrocardiogram when indicated) and functional assessment to identify high-risk conditions (for example recent MI/PCI/cardiac surgery within 90 days, heart failure, unstable angina, high-grade arrhythmias, or hemodynamically significant valvular disease).

Policy references the American Society of Anesthesiologists Physical Status Classification for assessing perioperative risk and cites literature and systematic review evidence regarding obesity and its association with increased respiratory complications and other predictors of complications/readmissions in ambulatory surgery.

Term	Definition
ASA I	A normal healthy patient.
ASA II	A patient with mild systemic disease without substantive functional limitations (examples include current smoker, pregnancy, obesity 30 < BMI < 40, well-controlled DM/HTN, mild lung disease).
ASA III	A patient with severe systemic disease with substantive functional limitations (examples include poorly controlled DM/HTN, COPD, morbid obesity BMI ≥40, ESRD on dialysis, history >3 months of MI/CVA/TIA or CAD/stents).
ASC	Ambulatory Surgery Center where patients return home same day as surgery.

Evidence: ASA Physical Status Classification — Amended 12/13/2020.

Evidence: Joshi GP et al., systematic review on selection of obese patients undergoing ambulatory surgery (Anesth Analg 2013) noting increased respiratory complications and perioperative risk in obesity.

Evidence: Literature on cardiovascular risk assessment and predictors of perioperative complications (e.g., risk models, ACS NSQIP calculator, and studies identifying high BMI, prior PCI or cardiac surgery, uncontrolled hypertension, prior TIA/stroke, prolonged operative time as predictors).

Evidence: Studies and reviews reporting predictors of unplanned readmissions and risk factors such as age >80, high BMI, and ASA physical classification score >2.

Revision History

07/25/2025retiredLatest

Policy retired.

02/19/2019revised

Consensus review with no changes to policy statements; references reviewed.

02/26/2020revised

Consensus review; policy statement unchanged, formatting updated, references reviewed.

AND NONE of the following

Age > 80> 80 years
Age exclusion
BMI > 40 kg/m2> 40 kg/m2
BMI exclusion
History of embolic event(s) (such as pulmonary embolism, transient ischemic attack or stroke) within 90 days of the anticipated date of surgerywithin 90 days
Recent embolic event exclusion window
Percutaneous coronary intervention (PCI), myocardial infarction (MI), or cardiac surgery within 90 days of the anticipated date of surgerywithin 90 days
Recent cardiac event exclusion window
Evidence of uncontrolled hypertension, unstable angina, high-grade dysrhythmias, heart failure, or hemodynamically significant valvular heart disease
High cardiovascular risk — inappropriate for ambulatory surgery
Patients requiring supplemental oxygen
Not appropriate for ambulatory surgical settings
End-stage renal disease (eGFR < 60 cc/min)eGFR < 60 cc/min
End-stage renal disease threshold
Fully dependent functional status
Fully dependent functional status exclusion
Known bleeding diathesis or anticoagulant use at the time of the procedure
Bleeding/anticoagulant exclusion
Severe dementia
Severe cognitive impairment exclusion

Consideration may be given for medically optimized patients with the following comorbid conditions

Consideration may be given for medically optimized patients with the following comorbid conditions (medical optimization and documentation required):

ANY of the following

Diabetes
Medical optimization required
HTN
Medical optimization required
Chronic renal disease (creatinine clearance < 60 cc/min)creatinine clearance < 60 cc/min
Renal disease consideration
Chronic liver disease (hepatitis, alcoholic liver disease, cirrhosis)
Medical optimization required
Coronary artery disease
Medical optimization required
COPD or severe asthma
Medical optimization required
Obstructive sleep apnea
Medical optimization required
Peripheral vascular disease
Medical optimization required
Carotid artery disease
Medical optimization required
BMI > 35 kg/m2> 35 kg/m2
Obesity consideration — medical optimization required