Prior Authorization Required

Prior authorization is required for site-of-service review for the elective procedures listed in this policy. Providers must request site-of-service prior authorization prior to scheduling the procedure when the procedure is among those subject to site-of-service review.

• Prior authorization requirement applies to listed elective surgical and diagnostic procedures.
• Requests must specify the proposed site of service (ASC, on-campus outpatient hospital, off-campus outpatient hospital, inpatient).
• Effective dates and code additions are reflected in the policy history and must be observed when submitting requests.

Documentation to Support Alternate Site

When requesting an alternate site of service (hospital outpatient or inpatient) instead of an ambulatory surgical center (ASC), providers must document clinical justification supporting why the ASC is not appropriate or accessible for the patient.

• Document why a geographically accessible ASC within 30 miles cannot provide the necessary care (no ASC with required equipment, no ASC where the physician has privileges, or ASC guidelines prohibit use for the individual's condition or weight).
• Document patient-specific factors such as age (e.g., individuals aged 18 or younger), concurrent services requiring hospital setting, or other clinical reasons necessitating a hospital outpatient or inpatient site.
• Include relevant clinical records, imaging, prior attempts to schedule at an ASC, and evidence of lack of ASC access when available.

Provider Actions and Denial Triggers

Providers are responsible for following policy requirements for prior authorization, site selection justification, and accurate place-of-service coding on claims. Failure to provide required documentation or meet criteria may result in denial of payment for the requested site of service.

• Use correct Place of Service codes on professional claims (19 = Off-Campus-Outpatient Hospital; 21 = Inpatient Hospital; 22 = On Campus-Outpatient Hospital; 24 = Ambulatory Surgical Center).
• Requests lacking necessary clinical justification for a non-ASC site may be denied as not medically necessary.
• Follow any additional provider-facing instructions in authorization communications, including submission timelines and required forms.

ASC Services Considered Medically Necessary When Criteria Met

Services provided at an ASC will be considered medically necessary when the policy criteria are met. Policy history contains effective dates and added procedure/code updates — ensure authorizations and claims reflect the applicable effective date and codes.

• Refer to the policy history for dates when procedures or CPT codes were added as ASC-eligible (e.g., shoulder arthroscopy CPT codes added effective 02/06/2026).
• Ensure the service meets the policy's clinical and access criteria to be approved at an ASC.
• If approval criteria are met, submit authorization for the ASC site with supporting documentation.