Premera Bluecross ASC Site-of-Service Update

Site-of-Service Coverage Criteria

Site-of-Service Medical Necessity Criteria

Covered when ALL of the following apply:

Primary determination: Preferred medically necessary site for listed elective procedures is the ambulatory surgical center when safe and appropriate.

ASC is preferred when criteria for hospital-level care are not present.

Conditions allowing hospital outpatient site

ASC access exceptions: There is no qualifying ASC within 30 miles that can provide the necessary care OR no geographically accessible ASC that has the necessary equipment OR no geographically accessible ASC at which the individual's physician has privileges OR an ASC's guideline prohibits use related to the individual's health condition or weight.No qualifying ASC within 30 miles
Geographic/access exceptions permit hospital outpatient site when ASC is not accessible or available.
Age or concurrent service: The individual is aged 18 or younger OR the service is being performed in conjunction with an additional service that requires use of a hospital outpatient department in the same operative session.
Concurrent hospital-level services or pediatric age may require hospital outpatient site.
Clinical risk factors requiring hospital-level site
- Anesthesia risk: ASA classification III or higher OR personal history of complication of anesthesia OR documentation of alcohol dependence or history of cocaine use OR prolonged surgery (> 3 hours).ASA classification III or higher; > 3 hours for prolonged surgery
  Refer to ASA classification examples.
- Cardiovascular risk: Uncompensated chronic heart failure (NYHA III/IV) OR recent MI (< 3 months) OR poorly controlled/resistant hypertension OR recent CVA (< 3 months) OR increased risk for cardiac ischemia (DES < 1 year or angioplasty < 90 days) OR symptomatic arrhythmia despite medication OR significant valvular heart disease.
  Any cardiovascular condition listed supports hospital-level site.
- Liver risk: Advanced liver disease (MELD score > 8).MELD > 8
  Higher MELD indicates need for hospital-level care.

Not medically necessary (inpatient): Inpatient hospital site is considered not medically necessary for listed elective surgical procedures unless hospital‑level indications (as above) are present.

Inpatient setting reserved for when hospital-level indications exist.

ASC Site-of-Service Inclusion (shoulder arthroscopy)

Shoulder arthroscopy procedures will be considered for ASC site-of-service when ALL criteria below are satisfied:

ASC inclusion for shoulder arthroscopy: Shoulder arthroscopy CPT codes (23700, 29805–29807, 29819–29828) are included for consideration as medically necessary at an ambulatory surgical center when the site-of-service criteria in this policy are met.

Codes were added effective per policy history; ASC consideration requires meeting the same access and clinical-safety criteria used for other procedures.

ASC access and privileges: ASC site may be used if a geographically accessible ASC (within 30 miles) has necessary equipment and the operating physician has privileges; otherwise hospital outpatient site may be required.No qualifying ASC within 30 miles

Geographic access exception applies consistently across listed procedures.

Clinical exclusions for ASC: ASC is not appropriate for shoulder arthroscopy if the individual has any clinical risk factor requiring hospital-level care (see clinical risk factors: ASA III+, prolonged surgery >3 hours, significant cardiac, pulmonary, hepatic, renal, bleeding disorder, pregnancy, morbid obesity [BMI ≥50], anticipated transfusion, etc.).

On-campus outpatient hospital and off-campus outpatient hospital sites are not considered medically necessary for the elective surgical procedures covered by this guideline when the site-of-service criteria are not met. The policy lists clinical risk factors and access exceptions that permit use of a hospital outpatient department; absent those criteria an ambulatory surgical center (ASC) is the preferred medically necessary site.

This medical policy does not apply to Medicare Advantage. The policy history documents effective dates and provider-notification timing for changes to ASC inclusion and other scope revisions; providers should follow the policy exclusions and effective dates noted in the history when determining applicability.

An inpatient hospital site is considered not medically necessary for the elective surgical procedures in this guideline unless one or more hospital-level indications are present. Hospital-level indications include the clinical risk factors and other exceptions listed in the criteria (for example, morbid obesity, pregnancy, bleeding disorders, anticipated transfusion, certain cardiac, pulmonary, hepatic, renal or anesthesia-related risks).

Services provided outside the policy criteria or delivered before the documented effective dates or provider-notification periods described in the policy history may not be considered medically necessary. The history specifies implementation and effective dates for changes (for example, ASC inclusion for shoulder arthroscopy and other revisions) that affect whether a given site-of-service request meets the guideline.

Procedure and Place-of-Service Coding

ENT / Rhinoplasty CPT codesCPT

30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip.
30420	Rhinoplasty, primary; including major septal repair.
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work).
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies).
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies).

ENT / Nasal and sinus endoscopy CPT codesCPT

31233	Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31235	Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy
31240	Nasal/sinus endoscopy, surgical; with concha bullosa resection.
31253	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration.
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior).
31255	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior).
31256	Nasal/sinus endoscopy, surgical, with maxillary antrostomy.
31257	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy.
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus.
31267	Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus.

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Surgical treatment of snoring and OSA CPTCPT

42145

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty)

Gastroenterology / UGI endoscopy CPT codesCPT

43235	Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing
43238	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
43239	Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
43242	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) including examination of stomach and duodenum

Hand surgery / Carpal tunnel CPT codesCPT

29848	Endoscopy, wrist, surgical, with release of transverse carpal ligament.
64721	Neuroplasty and/or transposition; median nerve at carpal tunnel.

Knee surgery CPT codesCPT

27415	Osteochondral allograft, knee, open.
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty).
28446	Open osteochondral autograft, talus (includes obtaining graft[s]).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s]).
29867	Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty).
29871	Arthroscopy, knee, surgical; for infection, lavage and drainage.
29873	Arthroscopy, knee, surgical; with lateral release.
29874	Arthroscopy, knee, surgical; for removal of loose body or foreign body.
29875	Arthroscopy, knee, surgical; synovectomy, limited.
29876	Arthroscopy, knee, surgical; synovectomy, major.

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Shoulder procedure CPT codesCPT

23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus.
29805	Arthroscopy, shoulder, diagnostic, with or without synovial biopsy.
29806	Arthroscopy, shoulder, surgical; capsulorrhaphy.
29807	Arthroscopy, shoulder, surgical; repair of SLAP lesion.
29819	Arthroscopy, shoulder, surgical; with removal of loose body or foreign body.
29820	Arthroscopy, shoulder, surgical; synovectomy, partial.
29821	Arthroscopy, shoulder, surgical; synovectomy, complete.
29822	Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures.
29823	Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures.
29824	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure).

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Spinal procedure / neurostimulator CPT codesCPT

63650	Percutaneous implantation of neurostimulator electrode array, epidural.
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
63661	Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy.
63662	Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy.
63663	Revision including replacement of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy.
63664	Revision including replacement of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy.
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver.
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver.

Shoulder Procedures CPT codes (covered)CPTCovered

23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded).
29805	Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure).
29806	Arthroscopy, shoulder, surgical; capsulorrhaphy.
29807	Arthroscopy, shoulder, surgical; repair of SLAP lesion.
29819	Arthroscopy, shoulder, surgical; with removal of loose body or foreign body.
29820	Arthroscopy, shoulder, surgical; synovectomy, partial.
29821	Arthroscopy, shoulder, surgical; synovectomy, complete.
29822	Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures.
29823	Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures.
29824	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure).

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Spinal Procedures CPT codes (listed for reference)CPT

63650	Percutaneous implantation of neurostimulator electrode array, epidural.
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
63661	Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed.
63662	Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed.
63663	Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed.
63664	Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed.
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling.
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver.

Place of Service (Professional Claims Codes)Revenue

19	Off-Campus-Outpatient Hospital (Place of Service code)
21	Inpatient Hospital (Place of Service code)
22	On Campus-Outpatient Hospital (Place of Service code)
24	Ambulatory Surgical Center (Place of Service code)

Geographic access / ASC distance

ThresholdNo qualifying ASC within 30 miles that can provide the necessary care

Examples of 'no qualifying ASC' reasonsNo geographically accessible ASC with necessary equipment; no ASC where the physician has privileges; ASC guideline prohibits use related to individual's condition/weight

ApplicationAllows hospital outpatient site consideration when ASC access criteria are not met

Morbid obesity threshold

Provider Requirements, Prior Authorization, and Denial Conditions

Prior Authorization

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 Required

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.

Background and Scope

Elective surgical procedures can be performed safely in multiple settings—ASCs, on- and off-campus outpatient hospitals, and inpatient hospitals—when selected based on patient safety and appropriateness. Site selection should consider clinical factors (such as ASA classification III or higher, significant cardiac, pulmonary, hepatic or bleeding risks, morbid obesity, pregnancy, or anticipated transfusion), availability and geographic access to a qualified ASC (the guideline references ASC access exceptions), and whether concurrent services require a hospital department. The policy updates reflect that, when criteria are met, certain procedures (for example, shoulder arthroscopy codes added in the 2026 history entry) may be considered medically necessary at an ASC; otherwise hospital-level care is appropriate only when hospital-level indications exist.

Key Definitions and Classifications

Site of service — definition

DefinitionPhysical location where the surgical procedure is performed (ambulatory surgical center, off-campus outpatient hospital/medical center, on-campus outpatient hospital/medical center, or inpatient hospital/medical center)

ExamplesASC, off-campus outpatient hospital, on-campus outpatient hospital, inpatient hospital

UseSite of service is reviewed for medical necessity when determining appropriate location for elective surgical procedures

Anesthesia risk (ASA classification)

DefinitionAnesthesia-related factor: ASA classification III or higher

ImplicationASA III+ listed as a clinical risk factor that may necessitate hospital-level site rather than ASC

Policy Revision History

08/01/25added

New utilization management guideline approved July 8, 2025; effective for dates of service on or after November 7, 2025, following 90-day provider notification — established ASC site-of-service review for select surgical procedures.

11/01/25added

Interim review approved October 14, 2025; effective February 6, 2026 (following 90-day provider notification) — added shoulder arthroscopy to ASC for Select Surgical Procedures and added CPT codes 23700, 29805-29807, 29819-29828 effective 02/06/26.

12/01/25revised

OpenPayer

Site-of-service criteria for elective surgical and diagnostic procedures in adults