CurrentColorado Rocky Mountain Health PlansPolicy MP.12.21

Office-Based Procedures – Site of Service – Commercial and Individual Exchange Medical Policy

Defines medical necessity criteria for performing elective surgical procedures in an ambulatory surgical center (ASC) versus an office setting for UnitedHealthcare Commercial and Individual Exchange plans (excludes certain states). Specifies when ASC site is covered and prior authorization requirements for listed procedures when not performed in-office.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOffice-Based Procedures – Site of Service – Commercial and Individual Exchange Medical Policy

Policy CodePolicy MP.12.21

Change TypeTemplate update / shared policy creation

Effective DateJan 1, 2026

Next Review Date

Key ActionPrior authorization is required for procedures listed in the Applicable Codes section if not performed in an office setting.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and added language excluding Massachusetts for Individual Exchange.

MultipleReferenced Procedure Codes

Prior auth requiredPA Requirement

Commercial & Individual ExchangePlan Scope

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy Number: MP.12.21; Subject: Office-Based Procedures - Site of Service (ASC vs office); Status: CURRENT; Plan scope: Applies to UnitedHealthcare Commercial & Individual Exchange plans (excludes certain states).

Effective Date: 2026-01-01; Last Review Date: 2026-01-01.

Key stats: • Referenced Procedure Codes: Multiple CPT codes listed • PA Requirement: Prior authorization required • Plan Scope: Applies to Commercial & Individual Exchange

Medical Necessity Criteria

Medically Necessary ASC Criteria for Elective Procedures

Elective procedures performed in an ambulatory surgical center are considered medically necessary when ANY of the following are met:

ANY of the following

Allergy to local anesthetic
Bleeding disorder that would cause a significant risk of morbidity
Developmental stage or cognitive status warranting use of an ambulatory surgical center
Failed office-based procedure attempts due to body habitus, abnormal anatomy, or technical difficulties
Presence of complications and comorbid disease that would cause office-based procedure to be unsafe or unsuitable

Medically Necessary ASC when office access unavailable

An elective surgical procedure performed in an ambulatory surgical center is considered medically necessary if there is an inability to access an office setting for the procedure due to either of the following:

ANY of the following

There is no geographically accessible office that has the necessary equipment for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, and nonstandard scopes required to perform specialized procedures such as duodenoscope, ureteroscope)
Specifically excludes surgeon preferred or proprietary instruments, instrument sets, or hardware sets
There is no geographically accessible in-network provider

Applicable Procedure Codes

Applicable Procedure Codes (reference list; prior authorization required if not performed in an office setting)CPT

11402	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 1.1 to 2.0 cm
11403	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 2.1 to 3.0 cm
11404	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 3.1 to 4.0 cm
11406	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter over 4.0 cm
11420	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less
11421	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm
11422	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm
11423	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
11424	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm
11426	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm

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Actionable Provider Requirements

Prior Authorization

Prior authorization requirement for listed procedures

Prior authorization is required for procedures listed in the Applicable Codes section if not performed in an office setting.

See the Applicable Procedure Codes group for affected CPT codes (reference list; prior authorization required if not performed in an office setting).

Documentation Required

Medical record documentation for review

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; benefits are determined by the member-specific benefit plan and documentation does not guarantee coverage.

Documentation does not guarantee coverage.

Billing Rule

Site of service coverage determination

If the ambulatory surgical center (ASC) is not considered medically necessary under the member's benefit plan, the ASC site will not be covered; check member-specific plan documents and any applicable mandates when determining coverage.

ASC coverage depends on medical necessity per the member-specific benefit plan and applicable laws/mandates.

Background & Definitions

This policy governs medical necessity review of site of service for elective office-based procedures, determining when ambulatory surgical center (ASC) use is medically necessary versus an office setting. If the ASC is not considered medically necessary, the ASC location will not be covered under the member's plan.

The policy incorporates patient safety principles and recommendations from the American College of Surgeons (ACS) and the American Society of Anesthesiologists (ASA) regarding office-based surgery and anesthesia, including guidance on patient selection, provider qualifications, facility capabilities, procedure complexity and recovery considerations.

Anesthesia selection and patient/procedure selection recommendations referenced include ensuring procedures are within practitioner and facility capabilities, are of appropriate duration and complexity to permit recovery and discharge, and that individuals at undue risk because of pre-existing conditions be referred to an appropriate facility for the procedure and anesthesia.

Office-based procedure: Procedures performed in an office setting as opposed to an ambulatory surgical center; ASC use requires medical necessity per listed criteria.

Revision History

2026-01-01revisionLatest

Template update; created shared policy version to support application to Oxford plan membership and added language excluding Massachusetts for Individual Exchange.

2026-01-01archivalLatest

Archived previous policy versions MP.12.20 and SURGERY 107.21 as part of the update creating the new shared policy (MP.12.21).