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.

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

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 / 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.

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 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.

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.

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 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.

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 / 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.

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.

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 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.

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.

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.

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.

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.

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 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.

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.

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).

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.

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.

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.

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.

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 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.

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.

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.