CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Elective Surgical Procedures (Level of Care Policy)

Governs prior authorization and level-of-care determinations for a wide range of elective surgical procedures for Kaiser Foundation Health Plan of Washington members, specifying when inpatient versus outpatient/ASC settings require additional review and documentation.

Policy Summary

PayerKaiser Permanente

PolicyElective Surgical Procedures — Level of Care (site-of-service, prior authorization guidance)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with detailed clinical rationale and supporting documentation when requesting inpatient level of care; hospital-based outpatient is the default.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+procedure categories

~200codes listed (approx.)

Multiplerequires Non‑Medicare inpatient review

Yesdocumentation required for inpatient

SomeMedicare IP-only flagged

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Coverage and Level-of-Care Criteria

Inpatient Level-of-Care Approval Criteria

Inpatient level-of-care approval criteria — hospital-based outpatient default; inpatient level of care may be approved only when ALL of the following are met:

ALL of the following

The procedure has prior authorization for the surgical procedure (medical necessity of the procedure is reviewed separately and must precede level-of-care determination).
Procedure must also meet applicable clinical appropriateness guidelines.
Documentation demonstrates that observation or hospital-based outpatient care is insufficient to safely manage the patient’s post-operative needs.
Requests lacking sufficient documentation may be denied or redirected to observation level of care.
Detailed supporting documentation is provided, including clinical rationale, relevant history and diagnostic results, justification for inpatient care, anticipated length of stay, and discharge plan.
- Acute kidney injury.
- Severe or persistent altered mental status.
- Ambulatory or appropriate activity level status is not achieved.
- Conversion to open or more complex procedure requiring inpatient care.
- Excessive drainage or bleeding from the operative site.
- Hemodynamic instability.
- Longer postoperative monitoring/treatment needed due to preoperative drug use (e.g., cocaine, amphetamines).
When applicable, hospital stays requiring 2 midnights will be considered for conversion to inpatient level of care.
- Advanced liver disease (MELD Score > 8).
- Severe renal disease (GFR ≤ 30 mL/min).
- Severe valvular heart disease.
- Stroke within the last 3 months.
- Unstable chronic lung disease (e.g., asthma, COPD).
- Unstable coronary artery disease or acute heart failure.
- Other unstable medical conditions (e.g., poorly controlled epilepsy).

Code listing (no criteria)

Code listing (no criteria). The following procedure and diagnosis code lists are provided for reference only. Inclusion does not imply coverage; benefit coverage is determined by member-specific contract and applicable law.

Codes across specialties (e.g., Bariatric, Cardiology, Dermatology, ENT, GI, General Surgery, Gynecology, Orthopedics, Neurosurgery, Electrical Stimulation Devices) are listed in the policy code tables and referenced sections. These code lists indicate whether non-Medicare inpatient submissions require review and whether Medicare inpatient-only designations apply. The full code lists and status markers (e.g., Requires Medical Necessity Review, Medicare IP Only indicated with 'X') are contained in the policy appendix.

Refer to the policy code tables for specific CPT/HCPCS codes and their review/status markers.

Procedure-level Review Stance and Medical Necessity Notes

Procedure-level review stance — summary guidance by specialty and submission type:

ANY of the following

Non‑Medicare members: When these procedures are submitted with inpatient level of care, a medical necessity review for level of care is required (many procedures also require a separate medical necessity review of the procedure/device itself).
Medicare members: Procedures listed as Medicare inpatient-only (marked with 'X' in the code tables) are governed by Medicare rules; this policy does not apply to Medicare inpatient-only procedures.
Certain procedures and device implantations (e.g., pacemakers, defibrillators, cardiac EP procedures, implantable neurostimulators, gastric electrical stimulators, cochlear implants, select orthopedic and spine procedures, selected ENT procedures, bariatric surgeries) require separate medical necessity review in addition to level-of-care review. Refer to the specific clinical review policies where indicated.
For any inpatient request, ensure supporting documentation addresses both medical necessity of the procedure/device and the justification for inpatient level of care as outlined in the inpatient criteria.

Review Requirements and Supporting Documentation

Supporting documentation and operational notes — what to include with inpatient requests:

ALL of the following

Detailed clinical rationale describing current condition and how it necessitates inpatient management rather than observation or outpatient care.
Relevant history, comorbidities, diagnostic results, and operative plan.
Clear justification for why observation care is insufficient, including anticipated post‑operative needs and potential complications.
Estimated length of stay and discharge planning, including anticipated resources needed for safe discharge.

Procedure and Code Listings

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required; hospital-based outpatient is default

Prior authorization is required for site-of-service for the elective surgical procedures listed in this policy; hospital-based outpatient is the default and preferred authorization status, and inpatient authorization must be justified with supporting documentation.

Request prior authorization for the intended site of service for listed elective outpatient surgical procedures.
If requesting inpatient level of care, include supporting documentation that justifies inpatient rather than hospital outpatient/ASC.

Prior Authorization

Inpatient medical necessity review required for listed cardiac/device codes

When any of the listed CPT or HCPCS cardiac and device procedure codes are submitted as inpatient for non‑Medicare members, submit the claim for medical necessity review per the code listings.

Submit inpatient (Non‑Medicare) claims for the listed cardiac/device CPT/HCPCS codes for medical necessity review (see code lists).

Background and Scope

Elective surgical procedures may be performed in inpatient, hospital outpatient, or ambulatory surgery center settings. This policy establishes that hospital‑based outpatient is the default/preferred site-of-service for listed elective procedures and requires prior authorization for site-of-service decisions; inpatient level of care must be justified with supporting clinical documentation meeting the policy's inpatient level‑of‑care approval criteria.

Definitions and Abbreviations

ASA physical Status Classification System

ASA physical status systemSubjective 5-class assessment of patient physiological status used to predict operative risk

Use in reviewASA class IV or V is listed as a procedure-related factor that may justify inpatient care

ReferenceASA definitions and examples referenced in document definitions section

Apnea Hypopnea Index (AHI)

Apnea Hypopnea Index (AHI)Number of apneas plus hypopneas per hour of sleep (events/hour)

Definition sourceDefined in document Definitions section

Clinical relevance

Document Revision History

2022-11-01policy_creation

MPC approved the new Elective Surgical Procedures (Level of Care) criteria (initial publication).

2023-03-22effective_date_update

Updated effective date to April 25, 2023.

2023-07-11scope_expansion

MPC approved expansion of the policy scope beyond initial procedures; effective date set for December 1, 2023.

Policy Summary

PayerKaiser Permanente

PolicyElective Surgical Procedures — Level of Care (site-of-service, prior authorization guidance)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with detailed clinical rationale and supporting documentation when requesting inpatient level of care; hospital-based outpatient is the default.

SourceLink

On This Page

Pain, fever, or vomiting not appropriate for ambulatory or observation care.

Severe procedural complications (e.g., bowel injury, airway compromise, vascular injury).

Unstable clinical status.

Anesthetic risk — ASA class IV or V.

Persistent electrolyte abnormalities unresponsive to treatment (e.g., hyperkalemia, hyponatremia).

Risk of postoperative airway compromise (e.g., open neck or airway surgery).

Complex surgical approach or complex postoperative wound care (e.g., extensive dissection, complex drain management, prior radiation or surgery, impaired circulation).

Follow referenced device-specific clinical review policies for pacemaker/defibrillator procedures where indicated.

Prior Authorization

Prior authorization / medical necessity review required for listed CPTs

Prior authorization / medical necessity review is required for the enumerated CPT codes when submitted as inpatient for Non‑Medicare members; codes flagged 'Requires Medical Necessity Review' (X) must undergo review.

When submitting listed CPTs as inpatient for Non‑Medicare members, request medical necessity review/authorization.
Codes marked 'Requires Medical Necessity Review = X' require submission of supporting clinical documentation to justify inpatient level of care.

Prior Authorization

Prior authorization / review requirements for General Surgery and vascular CPTs

Many General Surgery and vascular CPT codes require review when submitted as inpatient level of care; some entries carry Medicare inpatient-only or ASC/ASC‑SOC review flags which affect authorization routing.

Submit inpatient (Non‑Medicare) claims for these General Surgery and vascular CPTs for medical necessity review per the code entries.
If a code is marked with ASC/ SOC or Medicare IP Only indicators, follow the status and related review process shown in the listing.

Prior Authorization

Medical necessity review required for electrical stimulation devices

Electrical stimulation and neurostimulator implantation, revision, removal, and related device CPTs are designated as requiring medical necessity review when submitted (some items are also indicated Medicare inpatient‑only).

Submit inpatient (Non‑Medicare) requests for neurostimulator/electrical stimulation codes for medical necessity review.
Codes such as 64575, 64580, 64555, 64585, 64561, 64581, 61867, 63650, 63655, 63661, 63663, 63664, 63685, 63688, 43647, 43648, 43881, 64590, 64595 are examples requiring review.

Prior Authorization

Prior authorization required for listed CPTs (watch for Medicare 'X' markers)

Prior authorization / medical necessity review is required when the listed CPT codes are submitted (Non‑Medicare inpatient); some codes are marked with an 'X' to denote Medicare inpatient‑only status and are handled separately.

When requesting inpatient authorization for the listed CPTs, reference the exact CPT and include required supporting documentation.
Codes marked 'X' (Medicare IP Only) are not governed by the non‑Medicare inpatient review rules in this policy.

Prior Authorization

Inpatient medical necessity review required for GI endoscopy/G codes

Listed CPT and G codes for gastroenterology and endoscopy require medical necessity review when submitted as inpatient for non‑Medicare members; select endoscopic codes are flagged for ASC/medical necessity review or Medicare inpatient‑only.

Submit inpatient (Non‑Medicare) EGD/ERCP/colonoscopy and related codes for medical necessity review per the listed entries.
Codes flagged in the listing (e.g., 43235, 43236, 43239, 43241, 43242, 43245, 43246) carry ASC/Medical Necessity or Medicare IP Only indicators—follow those notations.

Prior Authorization

Review/authorization required for flagged General Surgery CPTs

For General Surgery CPTs in this segment, codes labeled 'Requires ASC SOC Review' or 'Requires Medical Necessity Review' must be submitted for the indicated review when billed as inpatient or for ASC site-of-service.

When codes such as 47562/47563 (cholecystectomy) or hernia repair codes are billed, use the review flags in the listing to determine whether ASC SOC review or medical necessity review is required.
Submit authorization requests referencing the exact CPT and any ASC/ SOC review requirement shown.

Prior Authorization

Prior authorization indicated for CPTs flagged with ASC/Medical Necessity markers

Selected CPT codes in this section are identified with review flags (e.g., ASC SOC Review or Medical Necessity Review); prior authorization or ASC SOC review is indicated for those procedures.

Review flags adjacent to CPT entries indicate required review type—follow the listed requirement when submitting prior authorization.
Examples include hernia and vascular access codes with ASC SOC or medical necessity indicators.

Prior Authorization

Submit listed CPT codes for review/authorization (general surgery & gynecology)

Many general surgery and gynecology CPT codes enumerated in the document require review when submitted as inpatient for Non‑Medicare members; submit these codes for review/authorization per the listings.

Submit inpatient (Non‑Medicare) authorization requests for the listed gynecology and general surgery CPTs.
Use the exact CPT from the listing and include the documentation indicated by the review flags.

Prior Authorization

Prior authorization / medical necessity review required for listed procedure codes

These codes (including orthopedic and other procedure groups shown) are indicated as requiring medical necessity review when submitted for inpatient level of care; some are also designated Medicare inpatient‑only.

When submitting inpatient claims for these codes, request medical necessity review and include supporting clinical documentation.
Codes marked 'Requires Medical Necessity Review' or with 'X' should be handled according to the listing.

Note

Use listed CPT codes when requesting prior authorization for orthopedic procedures

When requesting prior authorization for elective orthopedic procedures, reference the exact CPT codes listed in the policy's orthopedic code groups.

Provide the exact CPT code(s) from the orthopedic listings when submitting a prior authorization request.
The presence of a code in the orthopedic lists indicates it is referenced by the policy and may trigger level‑of‑care review.

Note

Listed orthopedic CPT codes (hand/wrist/forearm) — reference in authorizations

The hand, wrist and forearm orthopedic CPT codes are enumerated in this section; inclusion of a code in this list indicates it is subject to the policy's level‑of‑care and authorization references.

If performing hand/wrist/forearm procedures, reference the exact CPT from the listing when requesting authorization.
Check the code listing for any status flags (e.g., 'X' or review indicators) that affect review requirements.

Prior Authorization

Prior authorization for listed orthopedic CPTs — submit exact codes

Prior authorization may be required for specific orthopedic CPT codes listed; providers must reference the exact CPT code and any payer notation when requesting authorization.

When requesting authorization for an orthopedic procedure, include the exact CPT and any supporting clinical information.
Codes in this orthopedic segment may carry review flags—submit per instructions in the listing.

Note

Arthroscopy CPT codes listed — check master listing for authorization requirements

The arthroscopy CPT codes are listed here for reference; prior authorization requirements for these codes are specified elsewhere in the policy where applicable.

Use the code list to identify the appropriate CPT for shoulder, elbow, wrist and other arthroscopy procedures when requesting authorization.
Confirm whether the specific arthroscopy code has an 'X' or review flag in the master listing that mandates prior review.

Documentation Required

Required documentation for inpatient level-of-care requests

Providers must include detailed clinical rationale, relevant history and diagnostic results, explicit justification why observation care is insufficient, anticipated length of stay and discharge plan, and the last 6 months of clinical notes when requesting inpatient level-of-care authorization.

Attach last 6 months of clinical notes from the requesting provider and/or specialist to the prior authorization request.
Document attending provider justification that an overnight stay >2 midnights is expected and needed.

Documentation Required

Follow pacemaker/defibrillator clinical review policies for device inpatient claims

When submitting inpatient claims for the listed pacemaker and defibrillator procedures, follow the referenced Pacemaker and Cardiac Defibrillators Clinical Review Policies for medical necessity review requirements.

Include device‑specific review documentation per the Pacemaker and Cardiac Defibrillators Clinical Review Policies.
Submit inpatient (Non‑Medicare) device procedure claims for medical necessity review as noted in the code listings.

Documentation Required

Submit inpatient status and supporting documentation to trigger review

To trigger the inpatient medical necessity review for Non‑Medicare members, submit the procedure as inpatient and include supporting clinical documentation that establishes medical necessity and justifies the inpatient stay.

Ensure the claim is submitted with inpatient status for Non‑Medicare members when inpatient review is requested.
Provide clinical justification that observation care is insufficient and supporting diagnostic data as required.

Documentation Required

Include imaging and radiology documentation for vascular procedures

When billing vascular procedures listed in the revascularization sections, include imaging guidance and the radiological supervision/interpretation documentation necessary to perform the procedure when billed together.

Attach imaging guidance reports and radiologist S&I when stent placement or angioplasty and imaging are performed.
Document the imaging modality and intraprocedural findings used to support the intervention.

Documentation Required

Documentation required for device-related CPTs (neurostimulators)

Medical necessity review is required for multiple neurostimulator implantation, revision, removal, and pulse generator CPT codes; submit supporting clinical documentation for these device-related codes when requesting review or authorization.

Provide clinical indications, prior conservative therapies, and device trial results where applicable for codes such as 64575, 64580, 64555, 64585, 64561, 64581, 61867, 63650, 63655, 63661, 63663, 63664, 63685, 63688, 64590, 64595, 43647, 43648, 43881.
If a code is marked 'X', note the Medicare inpatient-only status for Medicare members and follow the applicable rules.

Documentation Required

Provide supporting documentation for flagged ENT/aural procedure codes

ENT, audiology, and related procedure codes flagged in the listing (e.g., cochlear implant 69930, BAHA 69710–69730 series, tympanostomy codes) require submission of supporting documentation per the listed review requirements.

Include operative notes, audiology testing, and device-specific indications when requesting prior authorization for ENT/auditory device procedures.
Follow the listing for any 'Requires Medical Necessity Review' or Medicare IP Only flags and submit documentation accordingly.

Billing Rule

Submit exact CPTs and corresponding clinical documentation

Submit the exact CPT procedure codes from the listings and include clinical documentation aligned with the level‑of‑care indicators (e.g., 'Requires Medical Necessity Review', ASC/SOC flags) when requesting review/authorization.

Use the precise CPT code(s) and descriptive titles from the policy's code lists in authorization requests.
Attach supporting clinical documentation corresponding to any review flags associated with the submitted CPT(s).

Documentation Required

Supporting documentation required for codes marked 'Requires Medical Necessity Review'

Procedures labeled 'Requires Medical Necessity Review' imply the need to submit supporting clinical documentation to justify the inpatient level of care; absence of sufficient documentation may result in denial or redirection to observation.

When a code is marked 'Requires Medical Necessity Review = X', include detailed clinical rationale and relevant test results to support inpatient admission.
Requests lacking sufficient documentation or failure to justify why observation is insufficient may be denied.

Denial Risk

Insufficient documentation may trigger denial or redirection to observation

Requests lacking sufficient documentation or failing to justify why observation care is insufficient may be denied or redirected to observation level of care.

Ensure inpatient requests contain the detailed clinical rationale, relevant history, diagnostics, anticipated stay, and discharge plan to avoid denial.
Document explicitly why observation care (≤2 midnights) is insufficient for the patient.

Denial Risk

Inpatient submission (Non‑Medicare) triggers medical necessity review

Submission of these procedures as inpatient for Non‑Medicare members will trigger a required medical necessity review and may be denied if review requirements are not met.

When billing listed procedures as inpatient for Non‑Medicare members, expect medical necessity review and provide required documentation up front.
Failure to submit the required information may result in denial of inpatient payment.

Denial Risk

Review required for Non‑Medicare inpatient submissions (cardiac/device codes)

Non‑Medicare inpatient submissions for the CPT codes in the cardiovascular and device sections require review when submitted as inpatient level of care; codes marked 'Requires Medical Necessity Review = X' must undergo medical necessity review.

If submitting cardiovascular/device CPTs as inpatient for Non‑Medicare members, include supporting clinical rationale and documentation to meet review requirements.
Codes explicitly flagged with 'X' indicate mandatory medical necessity review prior to approval.

Denial Risk

Failure to obtain required inpatient review may lead to denial

Submission as inpatient level of care for Non‑Medicare members requires review; failure to obtain required review may trigger denial of inpatient payment.

Obtain and submit medical necessity review for Non‑Medicare inpatient claims where the code listing indicates review is required.
Inpatient payment may be denied or administratively reclassified without adequate review documentation.

Denial Risk

Denial risk if medical necessity not established for 'X'-flagged device codes

Procedures flagged with 'Requires Medical Necessity Review = X' (including many device implantation/revision codes) may be denied if medical necessity is not established in the review.

Include detailed indication, prior treatments, and any device-trial results when submitting for these codes.
Anticipate additional information requests during the medical necessity review for X‑flagged codes.

Note

Non‑Medicare inpatient review required; Medicare 'X' items excluded

Non‑Medicare: inpatient submissions of listed procedures will require review; Medicare inpatient‑only procedures indicated with an 'X' are excluded from this non‑Medicare inpatient review policy.

For Medicare members, do not apply the non‑Medicare inpatient review process to procedures marked 'X' (Medicare IP Only).
For Non‑Medicare patients, submit inpatient claims for listed codes to trigger medical necessity review.

Prior Authorization

ASC/SOC review required for procedures marked with ASC SOC flag

Some procedures are marked 'Requires ASC SOC Review = X' indicating they require ASC/SOC review prior to approval and may trigger denial if that review requirement is not met.

When a procedure is marked for ASC SOC Review, follow the ASC site-of-care review process before performing the service in an ASC.
Failure to complete the ASC SOC review may result in denial or nonpayment for that setting.

May be considered when assessing perioperative respiratory risk

Acute Kidney Injury

Acute Kidney Injury diagnostic thresholdsIncrease in serum creatinine ≥0.3 mg/dL in 48 hours, or ≥1.5× baseline within 7 days, or >50% GFR reduction, or urine volume <0.5 mL/kg/hr for 6 hours

ContextAKI is listed among procedural events that may necessitate inpatient care

Reference guidelineKDIGO 2021 criteria summarized in Definitions section

Hemodynamic Instability

Hemodynamic instability definitionVital sign abnormalities not readily corrected, including persistent tachycardia, systolic BP <90 mm Hg or drop >40 mm Hg

Clinical elementsAlso includes MAP <70 mm Hg, persistent orthostatic hypotension, altered consciousness, or shortness of breath

Implication for level of careHemodynamic instability supports consideration for inpatient level of care when observation is insufficient

Pacemaker/Defibrillator procedures requiring medical necessity review

Device procedures requiring reviewPacemaker and defibrillator procedures are identified for medical necessity review when submitted as inpatient (Non‑Medicare)

Reference policiesRefer to Pacemaker and Cardiac Defibrillators Clinical Review Policies for device-specific requirements

ExamplesCodes such as 33206, 33207, 33264, 33270 and related HCPCS/C codes appear in device sections

Non-Medicare

Non‑Medicare definitionRefers to patients or claims not covered under Medicare; inpatient submissions of listed codes require review for these members

Policy implicationNon‑Medicare inpatient submissions of listed CPTs trigger medical necessity review per document

UsageTerminology used throughout code lists and review requirements

Requires Medical Necessity Review

'Requires Medical Necessity Review' indicatorCodes flagged with 'Requires Medical Necessity Review' (often shown as 'X') must undergo medical necessity review before authorization when applicable

ApplicationSeveral CPT entries across specialties include this indicator to trigger additional review for inpatient submissions

ImplicationFailure to establish medical necessity in review may lead to denial for inpatient billing

Mohs micrographic technique

Mohs micrographic techniqueRemoval of all gross tumor with mapping, color coding, microscopic examination and histopathologic preparation

Coding noteMohs CPT entries describe staged technique and tissue block handling as part of procedure descriptors

Clinical implicationProcedure-specific coding/blocks per stage are enumerated in dermatologic section

Medicare IP Only

Medicare IP Only notationProcedures designated inpatient-only for Medicare are marked with an 'X' and the policy's non‑Medicare review rules do not apply to those Medicare members

Document locations'X' markers appear in multiple specialty lists (e.g., GI, cardiology, general surgery) indicating Medicare inpatient-only status

Administrative effectFor Medicare members, follow Medicare inpatient-only rules rather than this non‑Medicare review framework when 'X' is present

Non‑Medicare inpatient review

Non‑Medicare inpatient review requirementInpatient submissions for non‑Medicare members of listed CPT codes require medical necessity review

ScopeApplies across multiple procedure families (cardiology, vascular, device implantation, etc.) as shown in code lists

ConsequenceFailure to submit for required review may result in denial or administrative nonpayment

Code notation 'X'

Policy notation 'X' meaning'X' adjacent to CPT entry indicates specific coverage or billing treatment (used in document as Medicare IP Only or other status markers)

Provider actionProviders should reference exact CPT code and any adjacent notation when requesting authorization or submitting inpatient claims

Document referenceCode notation legend is referenced across code lists though full legend not reproduced in extracted chunks

27759

27759 descriptorTreatment of tibial shaft fracture by intramedullary implant, with or without interlocking screws and/or cerclage

Coding contextListed among orthopedic procedure codes; no additional threshold specified in cited chunk

UseUse code 27759 for intramedullary tibial shaft fixation per operative technique

29826

29826 descriptorArthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament release

Coding contextListed in orthopedic arthroscopy code group; may be marked with status markers in code lists

Clinical implicationProcedure description aligns with typical acromioplasty/decompression operative reports for code selection

2023-10-06effective_date_change

Effective date changed to December 05, 2023.

2024-05-02medical_necessity_update

MPC approved medical necessity review for bladder sling procedures and updated applicable codes; effective August 1, 2024.

2024-05-10code_update

Added CPT code 27236 to the policy.

2024-07-02code_list_expansion

MPC approved addition of ASC SOC codes to the Level of Care Policy; effective December 1, 2024.

2024-11-18code_removal

Removed applicable codes for TAVR, MitraClip, and Watchman device.

2025-03-03review_requirement_update

Added indication that Shoulder Arthroscopy codes and Thyroidectomy procedures require Medical Necessity Review in addition to Level of Care review; removed duplicate codes.

2025-05-06cardiac_ep_criteria

MPC approved criteria for Cardiac Catheter EP-based procedures and added codes requiring Level of Care review.

2025-09-02policy_default_change

MPC approved changes to make hospital-based outpatient care the default for elective surgeries; effective February 1, 2026.

2025-10-01code_update

Updated applicable codes for artificial spinal discs with new medical necessity and level-of-care requirements effective October 1, 2025.

2025-11-04medical_necessity_addition

MPC approved medical necessity review for Non‑Surgical procedures for Knee Pain and updated applicable codes to the level-of-care section effective April 1, 2026.

2025-12-22medicare_ip_list_changeLatest

Removed codes from the Medicare inpatient-only list for Shoulder Arthroplasty, Total Hip and Total Knee Arthroplasty effective January 1, 2026.