CurrentEvolentPolicy 1755

Evolent Place of Service Policy 1755 for Interventional Pain Management

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This policy governs the appropriate setting and place-of-service reporting for elective interventional pain management procedures. It generally directs care to a physician office or ambulatory surgery center, while permitting outpatient hospital care when documented patient-specific risks or clinical circumstances justify that setting.

Policy Summary

PayerEvolent

PolicyPlace of Service for Interventional Pain Management

Policy CodePolicy 1755

Change TypeNo material change

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionReport the place-of-service code corresponding to where the interventional pain management procedure was performed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POS 11Physician office setting

POS 24Ambulatory surgery center setting

POS 22Outpatient hospital setting

≥3ASA criterion

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CurrentEvolentPolicy 1755

Evolent Place of Service Policy 1755 for Interventional Pain Management

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Policy Summary

PayerEvolent

PolicyPlace of Service for Interventional Pain Management

Policy CodePolicy 1755

Change TypeNo material change

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionReport the place-of-service code corresponding to where the interventional pain management procedure was performed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POS 11Physician office setting

POS 24Ambulatory surgery center setting

POS 22Outpatient hospital setting

≥3ASA criterion

5Sedation and anesthesia levels

Selection of Outpatient Hospital Setting

Selection of outpatient hospital setting

Elective interventional pain management procedures generally belong in a physician office or ambulatory surgery center. Outpatient hospital care is appropriate only when at least one qualifying patient criterion is met and the required additional documentation is provided.

ALL of the following

ONE or more qualifying criteria
- The patient has an American Society of Anesthesiologists Physical Status (ASA PS) score of 3 or higher.ASA PS ≥ 3
- The patient has a body mass index of 40 or higher, with or without an obesity-related condition or unmanaged comorbidities.BMI ≥ 40
- ONE or more moderate-to-severe health conditions
  - Heart problems, including prior heart surgery, heart attack, heart failure, coronary artery disease or stents, arrhythmia, pacemaker, or defibrillator.
  - Lung problems, including COPD or asthma.
  - Chronic kidney or liver problems, including kidney failure or cirrhosis or active hepatitis.
  - Blood clots or a bleeding disorder.
  - Stroke or transient ischemic attack (TIA).
  - High blood pressure requiring 3 or more drugs to control.3 or more drugs
  - Poorly controlled diabetes.
  - Cognitive impairment or dementia.
  - Pregnancy.
  - A substance use disorder, including cannabis, hallucinogen, inhalant, opioid-related, sedative/hypnotic/anxiolytic, stimulant, or alcohol use disorder.
  - Prior anesthesia complications, including a personal or family history.
  - An anticipated difficult airway.
  - Sleep apnea.
  - A history of anaphylaxis to medication, latex, or iodine.
Additional documentation supporting the qualifying criterion is provided by the treating physician and/or primary care physician.
Required for all outpatient hospital selection criteria.

Place-of-Service Coding and Clinical Thresholds

Place-of-service codes for interventional pain managementmixed

22	Outpatient hospital on campus: A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
24	Ambulatory surgery center: A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
11	Physician office: Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

ASA Physical Status

ThresholdASA Physical Status score ≥ 3

SupportsOutpatient hospital care when additionally documented

DocumentationAll criteria require additional documentation from the treating physician and/or primary care physician

Body mass index

ThresholdBody mass index (BMI) ≥ 40

Additional conditionsQualifies with or without an obesity-related condition or unmanaged comorbidities

Documentation

Documentation, Authorization, and Reporting Requirements

Documentation Required

Submit supporting clinical documentation

Provide appropriate supporting documentation for all requests. Include recent pertinent office visit notes, laboratory data, results of special testing, and, when applicable, prior relevant imaging results and the reason alternative imaging cannot be performed.

Prior Authorization

Document hospital-setting justification

When requesting outpatient hospital care, the treating physician and/or primary care physician must provide additional documentation supporting at least one qualifying patient criterion. Qualifying criteria include ASA PS score ≥ 3, BMI ≥ 40, or a moderate-to-severe health condition listed in the policy.

Place-of-Service and Sedation Definitions

Outpatient hospital on campus

Place-of-service codePOS 22

FacilityA portion of a hospital's main campus

ServicesProvides diagnostic, therapeutic—including surgical and nonsurgical—and rehabilitation services

Patient settingFor sick or injured persons who do not require hospitalization or institutionalization

Ambulatory surgery center

Place-of-service codePOS 24

FacilityA freestanding facility other than a physician's office

Policy Summary

PayerEvolent

PolicyPlace of Service for Interventional Pain Management

Policy CodePolicy 1755

Change TypeNo material change

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionReport the place-of-service code corresponding to where the interventional pain management procedure was performed.

SourceLink

On This Page

All criteria require additional documentation from the treating physician and/or primary care physician

Hypertension treatment burden

Qualifying conditionHigh blood pressure requiring 3 or more drugs to control

ClassificationA moderate-to-severe health condition supporting outpatient hospital care

DocumentationAll criteria require additional documentation from the treating physician and/or primary care physician

Billing Rule

Report the actual place of service

Report the place-of-service code corresponding to where the interventional pain management procedure was performed. Place of service affects facility reimbursement and claims-based program reporting.

POS 11 — Physician office
POS 24 — Ambulatory surgery center
POS 22 — Outpatient hospital on campus

Prior Authorization

Verify plan-specific authorization and coverage

Verify each member’s coverage, prior authorization requirements, and service limitations before providing the procedure. Coverage and requirements vary according to the individual member’s health plan or government program.

ServicesSurgical and diagnostic services are provided on an ambulatory basis

Physician office

Place-of-service codePOS 11

LocationAn ambulatory location other than a hospital, skilled nursing facility, military treatment facility, community health center, state or local public health clinic, or intermediate care facility

ServicesHealth professionals routinely provide health examinations, diagnosis, and treatment of illness or injury

Sedation and analgesia continuum

Minimal sedation (anxiolysis)The patient responds normally to verbal commands; cognitive function may be impaired, but vital functions are unaffected.

Moderate sedation (conscious sedation)The patient responds purposefully to verbal or tactile stimulation; airway and cardiovascular functions are maintained.

Deep sedationThe patient cannot be easily aroused but responds to repeated or painful stimuli; airway intervention may be required.

General anesthesiaThe patient is unarousable even by painful stimuli; airway and cardiovascular functions may be impaired.