Site-of-care prior authorization for selected outpatient surgical procedures (Gastroenterology and related specialties)
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Defines prior authorization and site-of-care medical necessity criteria for selected elective outpatient surgical procedures (notably GI, general surgery, and plastic surgery) in specified Washington counties, affecting Kaiser Permanente providers and members.
MPC approved an expansion of the ASC criteria and adoption of SOC restriction for Gastroenterology procedures, applicable to King and Thurston counties in addition to existing counties.
Updated 'site of service' terminology to 'site of care' throughout the policy.
Site-of-Care Medical Necessity Criteria
Medically necessary when ANY of listed clinical risk conditions exist
A planned elective surgical procedure performed in a hospital outpatient department is considered medically necessary for site-of-care reasons when ANY one of the following clinical conditions or access issues applies:
From policy examples of conditions
Threshold as listed in policy
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
Threshold as listed in policy
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
Age threshold listed in policy
From policy examples of conditions
Duration threshold listed in policy
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
From policy examples of conditions
Medically necessary when access to ASC is unavailable
A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when there is inability to access an ambulatory surgical center due to ANY one of the following:
Access barrier listed in policy
Access barrier listed in policy
Access barrier listed in policy
Inpatient hospital may be necessary when patient at risk of complications
Examples when elective surgery at an inpatient hospital/medical center may be considered medically necessary due to risk of complications include:
Example risk from policy
Example risk from policy
Example risk from policy
Example risk from policy
Example risk from policy
Example risk from policy
ASC Site-of-Care Criteria Expansion
ASC site-of-care criteria and Gastroenterology SOC restrictions apply as designated by the MPC:
Providers must verify authorization requirements for specific codes and plan types using the Pre-authorization Code Check
Listing of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is covered or not covered. Benefit coverage for any service is determined by the member-specific contract and applicable law, and the inclusion of a code in this policy does not guarantee reimbursement or claim payment. Other policies and guidelines may apply.
The policy extract presents lists of CPT procedure codes grouped by specialty and county for reference (for example, plastic surgery codes such as 19316, 19318, 19325 are shown for Benton, Kitsap, Spokane, and Whatcom counties). These sections in the document are code listings and do not state additional explicit exclusions within the provided chunks; they serve to indicate which procedures are addressed on the criteria page.
Some codes listed in the policy may have been deleted or may not be in effect at the time of service; such deleted or inactive codes may not be covered. The code lists are not all-inclusive and providers should verify current code validity and coverage via the Pre-authorization Code Check prior to submission.
Within the provided document chunks there are no statements labeling services as ‘not medically necessary’. The included excerpts are primarily procedural code listings and related descriptors rather than negative coverage determinations.
CPT / HCPCS Code Listings
| 24220 | Injection procedure for elbow arthrography |
| 24331 | Flexor-plasty, elbow (Steindler type advancement) with extensor advancement |
| 24371 | Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component |
| 24495 | Decompression fasciotomy, forearm, with brachial artery exploration |
| 25111 | Excision, lesion of tendon sheath, forearm and/or wrist |
| 25116 | Radical excision of bursa, synovia of wrist; or forearm tendon sheaths; extensors, with or without transposition of dorsal retinaculum |
| 25119 | Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna |
| 25120 | Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process) |
| 25125 | Excision or curettage of bone or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process) with autograft |
| 25126 | Excision or curettage of bone cyst or benign tumor of radius or ulna with allograft |
Authorization, Verification, and Documentation Requirements
Prior Authorization Required
Prior authorization is required to verify the appropriate site-of-care for certain elective outpatient surgical procedures. Use the Pre-authorization Code Check to verify authorization requirements for a specific CPT/HCPCS code by plan type.
- Verify member coverage and any existing authorization prior to scheduling.
- For Non‑Medicare members, site-of-care rules are implemented in a phased county rollout (see policy for county-specific applicability).
- If the procedure will be performed in a hospital outpatient department, confirm whether any of the listed clinical exceptions apply (e.g., anticipated overnight recovery, advanced liver disease, anticipated transfusion, brittle diabetes, bleeding disorders requiring products, symptomatic arrhythmia despite medication, COPD with FEV1 <50%).
Procedure Codes and Descriptors Included
This section lists CPT/HCPCS procedure codes associated with the site-of-care review. Inclusion of a code is for reference only and does not by itself indicate coverage or authorization status. Verify requirements and whether codes are in effect or deleted at time of service.
- The section contains numerous CPT codes with short descriptors (e.g., 43191 Esophagoscopy, rigid; 43202 Esophagoscopy, flexible with biopsy; 19316 Mastopexy; 23130 Acromioplasty; 26437 Realignment of extensor tendon; 29906 Arthroscopy, subtalar joint; 64721 Neuroplasty/transposition of median nerve at carpal tunnel).
- Codes provided are not all-inclusive; deleted or obsolete codes may be present.
- Use Pre-authorization Code Check to confirm current code status and authorization needs.
Provider Action — Authorization/Denial Triggers and Criteria
No explicit authorization or denial triggers or specific authorization/denial criteria are restated in these provider-action chunks. Providers must rely on the Pre-authorization Code Check and member-specific Evidence of Coverage for final determination.
- The policy excerpts do not provide stepwise authorization decision rules in this section.
- There are no unique authorization thresholds or explicit denial criteria listed in the extracted provider-action text.
- When clinical exceptions apply (see policy clinical criteria), document the relevant clinical information in the authorization request to support medical necessity review.
Verification and Documentation Requirements
Verify authorization and document supporting clinical information in the medical record and in any authorization request.
- Confirm member eligibility, benefits, and whether a prior authorization already exists before scheduling.
- When submitting an authorization request, include clinical rationale and documentation that supports any applicable exception (e.g., anticipated need for overnight recovery, MELD score, transfusion need, pulmonary function results, cardiac or bleeding disorder documentation).
- Use Pre-authorization Code Check to determine whether site-of-care review and prior authorization apply to the planned procedure and setting.
Background and Scope
Surgical procedures may be performed in a variety of settings, including an inpatient hospital/medical center, an off‑campus or on‑campus outpatient hospital/medical center, an ambulatory surgical center (ASC), or a physician office. To support safe and appropriate site selection, the plan requires prior authorization for certain elective outpatient surgical procedures to review and approve the appropriate site of care.
Key Definitions and Code Examples
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