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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyPremera Bluecross ASC Site‑of‑Service Coverage Upd…
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    DraftPremera BluecrossPolicy N/A

    Site of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults

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    Defines medical necessity criteria and prior authorization requirements for the site of service (ASC, on-/off-campus outpatient hospital, inpatient) for selected elective adult surgical and diagnostic procedures for Premera members.

    Policy Summary
    PayerPremera Bluecross
    PolicySite of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults
    Policy CodePolicy N/A
    Change TypeAdds shoulder arthroscopy, hand surgery codesexpands to include diagnostic procedures
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review Date
    Key ActionObtain prior authorization for site of service review when indicated by the policy for listed elective procedures.
    SourceLink
    POLICY UPDATE CHANGES

    Added shoulder arthroscopy to ASC for Select Surgical Procedures as medically necessary when criteria are met and added CPT codes 23700, 29805-29807, 29819-29828 effective 02/06/26.

    Title changed to include diagnostic procedures and Upper Gastrointestinal (UGI) Endoscopy (2.01.533) added to list requiring review for ASC site of service.

    Added Hand Surgery section to include carpal tunnel release surgical techniques and CPT codes 29848 and 64721.

    Minor update to ASA Physical Status Classification table to include adult examples.

    multipleprocedure categories listed
    extensiveCPT/HCPCS code lists
    30 milesASC access distance
    ASA III+anesthesia risk threshold
    BMI ≥50morbid obesity threshold

    Site-of-Service Coverage Criteria

    Site-of-service medical necessity criteria

    Covered when ALL of the following are met

    Site selection: Certain elective surgical procedures will be covered in the most appropriate, safe, and cost-effective site of service, with ambulatory surgical center (ASC) as the preferred medically necessary site when criteria allow.ASC preferred

    ASC is preferred site when criteria allow

    When hospital outpatient is allowed: An elective procedure performed in a hospital outpatient department may be considered medically necessary if there is no qualifying ASC within 30 miles that can provide the necessary care OR the individual's physician lacks ASC privileges OR an ASC's specific guideline prohibits use related to the individual's health condition or weight.No ASC access within 30 miles or no privileges or ASC prohibition

    Geographic/equipment/privilege/access exceptions

    Policy Summary
    PayerPremera Bluecross
    PolicySite of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults
    Policy CodePolicy N/A
    Change TypeAdds shoulder arthroscopy, hand surgery codesexpands to include diagnostic procedures
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review Date
    Key ActionObtain prior authorization for site of service review when indicated by the policy for listed elective procedures.
    SourceLink
    On This Page
    Site-of-Service Coverage CriteriaProcedure and Billing CodesPrior Authorization, Documentation, and Billing RequirementsBackground and ScopeKey Definitions and ClassificationsPolicy Revision History
    Other exceptions: The hospital outpatient site may also be necessary when the individual is aged 18 or younger OR the service is performed in conjunction with an additional service that requires a hospital outpatient department and both are performed in the same operative session.Age <=18 or concurrent hospital-requiring service
    High clinical risk: Hospital outpatient or inpatient site may be medically necessary if the individual has clinical conditions placing them at increased risk for complications (examples include ASA classification III or higher, recent MI less than 3 months, NYHA class III or IV, MELD score >8, FEV1 <50%, poorly controlled asthma with FEV1 <80% despite treatment, moderate–severe OSA, end-stage renal disease on dialysis, morbid obesity BMI >=50, pregnancy, bleeding disorder requiring replacement factor or transfusion, anticipated need for transfusion, substance use risks, or prolonged surgery >3 hours).Listed clinical risk conditions

    List may not be exhaustive

    ASC Medical Necessity for Select Procedures

    ASC site-of-service is considered medically necessary when policy criteria are met for select procedures (including added shoulder arthroscopy codes).

    ASC Medical Necessity: ASC site-of-service is medically necessary for listed procedures when criteria in the policy are met and applicable site-of-service review has been completed.

    See related procedure-specific policies and obtain prior review when indicated by the policy

    On-campus and off-campus outpatient hospital/medical center sites are considered not medically necessary for the elective surgical procedures listed in this guideline when the site-of-service criteria are not met. The policy identifies the Ambulatory Surgical Center (ASC) as the preferred, most appropriate site when criteria allow; hospital outpatient locations should be used only when the policy exceptions or criteria (for example, lack of an accessible ASC within 30 miles, absent ASC privileges, or listed clinical risk factors) apply.

    Coverage may be limited by the member’s contract. Providers must consult the member benefit booklet or contact customer service to determine whether a specific member’s benefits exclude coverage for services or sites of service addressed in this policy. The policy explicitly notes that member contract limitations can affect applicability and that separate benefit determination is required.

    Inpatient hospital/medical center care for the elective surgical procedures addressed in this guideline is considered not medically necessary unless the individual meets separate inpatient medical necessity criteria. Hospital admission should only be used when inpatient-specific indications are present and documented.

    Coverage determinations are subject to member benefit limits and must follow the policy criteria for site of service. The document reiterates that ASC eligibility and any non-ASC justification are governed by the policy rules and by the member’s contract; specific not-medically‑necessary conditions and benefit limitations are addressed elsewhere in the policy and related sections.

    Procedure and Billing Codes

    Knee surgery CPT codesCPTCovered
    27415Osteochondral allograft, knee, open.
    27416Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]).
    28446Open osteochondral autograft, talus (includes obtaining graft[s]).
    29866Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s]).
    29867Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty).
    ENT — Rhinoplasty CPT codesCPTCovered
    30400Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
    30410Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip.
    30420Rhinoplasty, primary; including major septal repair.
    30430Rhinoplasty, secondary; minor revision (small amount of nasal tip work).
    30435Rhinoplasty, secondary; intermediate revision (bony work with osteotomies).
    30450Rhinoplasty, secondary; major revision (nasal tip work and osteotomies).
    ENT — Nasal/sinus endoscopy CPT codesCPTCovered
    31233Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure).
    31235Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium).
    31240Nasal/sinus endoscopy, surgical; with concha bullosa resection.
    31253Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed.
    31254Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior).
    31255Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior).
    31256Nasal/sinus endoscopy, surgical, with maxillary antrostomy.
    31257Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy.
    31259Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus.
    31267Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus.
    1–10 of 17
    1/2
    Breast surgery CPT codesCPTCovered
    19318Reduction mammaplasty.
    Gastroenterology — UGI endoscopy CPT codesCPTCovered
    43235Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).
    43238Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s).
    43239Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple.
    43242Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis).
    Hand surgery CPT codes (carpal tunnel)CPTCovered
    29848Endoscopy, wrist, surgical, with release of transverse carpal ligament.
    64721Neuroplasty and/or transposition; median nerve at carpal tunnel.
    Shoulder procedure CPT codesCPTCovered
    29805Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure).
    29806Arthroscopy, shoulder, surgical; capsulorrhaphy.
    29807Arthroscopy, shoulder, surgical; repair of SLAP lesion.
    29819Arthroscopy, shoulder, surgical; with removal of loose body or foreign body.
    29820Arthroscopy, shoulder, surgical; synovectomy, partial.
    29821Arthroscopy, shoulder, surgical; synovectomy, complete.
    29822Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures.
    29823Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures.
    29824Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure).
    29825Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation.
    1–10 of 13
    1/2
    Spinal procedures CPT codesCPTCovered
    63650Percutaneous implantation of neurostimulator electrode array, epidural.
    63655Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
    63661Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed.
    63662Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed.
    63663Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed.
    63664Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed.
    63685Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling.
    63688Revision or removal of implanted spinal neurostimulator pulse generator or receiver.
    Cardiac monitoring CPT codeCPTCovered
    33285Insertion, subcutaneous cardiac rhythm monitor, including program.
    HCPCS and Other codesmixedCovered
    J7330Autologous cultured chondrocytes, implant.
    S2112Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells).
    HCPCS codes (cardiac)HCPCSCovered
    E0616Implantable cardiac event recorder with memory, activator, and programmer.
    Shoulder and Spinal Procedures (CPT)CPT
    23700Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
    29805Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)
    29806Arthroscopy, shoulder, surgical; capsulorrhaphy
    29807Arthroscopy, shoulder, surgical; repair of SLAP lesion
    29819Arthroscopy, shoulder, surgical; with removal of loose body or foreign body
    29820Arthroscopy, shoulder, surgical; synovectomy, partial
    29821Arthroscopy, shoulder, surgical; synovectomy, complete
    29822Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures
    29823Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures
    29824Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
    1–10 of 22
    1/3
    Additional procedure and HCPCS codes added in historymixed
    33285Insertion of implantable loop recorder (per policy history addition)
    E0616Mobile Cardiac Outpatient Telemetry equipment (HCPCS) (per related additions)
    29848Arthroscopy, wrist or other — (carpal tunnel related insertion - added to hand surgery section)
    64721Neuroplasty and/or transposition; median nerve at carpal tunnel
    Geographic ASC access — No qualifying ASC within 30 miles
    ThresholdNo qualifying ASC within 30 miles that can provide necessary care
    Examples of lack of ASC accessNo geographically accessible ASC with necessary equipment; no ASC where physician has privileges; ASC guideline prohibits use due to individual's health condition or weight
    Related allowanceHospital outpatient may be considered medically necessary when no qualifying ASC within 30 miles
    ASA classification / clinical risk — ASA class III or higher; other clinical risk criteria
    Primary anesthesia risk criterionASA classification III or higher
    Other high-risk clinical criteria (examples)Recent MI < 3 months; NYHA Class III or IV heart failure; MELD score > 8; COPD with FEV1 < 50%; poorly controlled asthma (FEV1 < 80% despite treatment); moderate–severe OSA; ESRD on dialysis
    Perioperative concernsPersonal history of complication of anesthesia; prolonged surgery (>3 hours); documentation of substance use (alcohol dependence, cocaine) increases risk
    Morbid obesity — BMI >= 50
    BMI thresholdMorbid obesity defined as BMI greater than or equal to 50
    ASA contextMorbid obesity appears as an example of ASA III/IV-level physiologic risk (ASA III includes morbid obesity BMI ≥40) in ASA classification table
    ImplicationMorbid obesity is listed as a condition that may necessitate hospital outpatient or inpatient site rather than ASC
    NYHA walking distance example — Class III: walking short distances 20-100 m
    NYHA Class III exampleMarked limitation in activity; walks short distances (20–100 m); comfortable only at rest
    Functional impactSymptoms with less-than-ordinary activity indicating significant activity limitation
    Implication for site selectionNYHA Class III/IV may indicate need for hospital outpatient or inpatient setting rather than ASC

    Prior Authorization, Documentation, and Billing Requirements

    Prior Authorization

    Prior Authorization Required for ASC Site of Service

    Prior authorization is required for the site of service for the listed elective ambulatory surgical procedures. Providers must obtain authorization when performing applicable procedures in a non‑preferred site (for example, hospital outpatient department) unless criteria for a non‑ASC site are documented and met.

    • Prior authorization required for ASC site-of-service review for select elective procedures.
    • Failure to obtain prior authorization when required may result in denial of coverage for the site of service.
    Prior Authorization

    ASC Site-of-Service Review Required

    Certain procedures (including specified shoulder arthroscopy and other listed CPT codes) are included in the ASC site-of-service policy and require site-of-service review to determine medical necessity for performance at an Ambulatory Surgical Center (ASC). When criteria are met the ASC is the preferred medically necessary site for these select procedures.

    • Examples of procedures added to the ASC list include shoulder arthroscopy (see policy history additions effective 02/06/26) and other CPT codes added in subsequent updates.
    • Site-of-service review will determine whether the ASC is the most appropriate, safe, and cost‑effective location for the procedure.
    Documentation Required

    Required Documentation to Justify Non‑ASC Site

    Providers must document clinical indications and specific factors that justify performing the procedure in a non‑ASC site when an ASC is the preferred site. Acceptable documentation includes evidence that no geographically accessible ASC exists with necessary equipment or physician privileges, patient age (≤18 years), need to perform the service in the same operative session as an additional service that requires a hospital outpatient department, or clinical conditions that increase risk for complications (for example ASA III or higher, recent MI, advanced liver disease, end‑stage renal disease on dialysis, severe pulmonary disease, etc.).

    • Document why an ASC is not geographically accessible within 30 miles or lacks required equipment or physician privileges.
    • Document patient‑specific clinical risks or comorbidities (e.g., ASA classification III+, recent MI <3 months, NYHA III–IV heart failure, MELD >8, COPD with FEV1 <50%, dialysis dependence) that necessitate a hospital setting.
    • If the procedure is being performed with an additional service that requires hospital outpatient department resources, document that both services are being performed in the same operative session.
    Billing Rule

    Place of Service Coding, Benefit Verification, and ASC Criteria

    Place of service must be coded correctly on professional claims and providers should verify member benefits prior to scheduling. Services performed at an ASC for select procedures require meeting the applicable policy criteria and appropriate review; failure to meet criteria or to obtain authorization may result in denial of coverage for the site of service.

    • Use correct Place of Service codes on professional claims (e.g., 19 = Off‑Campus‑Outpatient Hospital, 21 = Inpatient Hospital, 22 = On‑Campus Outpatient Hospital, 24 = Ambulatory Surgical Center).
    • Verify member benefits to determine coverage limitations and whether this medical policy applies to the member's plan.
    • Services performed at a non‑ASC site when criteria are not met may be considered not medically necessary for that site and denied.
    Denial Risk

    Denial Trigger: Site‑of‑Service Criteria Not Met

    Site-of-service requests that do not meet ASC criteria or lack required documentation are a potential denial trigger. If the documented clinical indications do not justify a non‑ASC site or prior authorization was not obtained when required, the site of service may be considered not medically necessary and coverage for the non‑ASC setting may be denied.

    • Denial risk exists when documentation does not demonstrate one of the acceptable reasons to avoid ASC placement (geographic access, equipment/privileges, age ≤18, concurrent hospital‑required service, or qualifying clinical risk factors).
    • Obtain and supply supporting clinical records with the authorization request to reduce denial risk.
    Prior Authorization

    ASC Site‑of‑Service Criteria and Review

    Services performed at an ASC for select procedures require meeting policy criteria and appropriate review. Providers should ensure criteria are met and authorization is obtained when required; failure to meet criteria or to obtain authorization may affect coverage and reimbursement.

    • ASC site‑of‑service criteria include clinical risk factors, age, concurrent procedures, and geographic/access considerations as described in the policy coverage guidelines.
    • When in doubt, submit a site‑of‑service review request with supporting documentation prior to scheduling.

    Background and Scope

    Elective surgical procedures may be performed in multiple settings — Ambulatory Surgical Centers (ASC), on‑campus and off‑campus outpatient hospital/medical centers, or inpatient hospitals. This policy prefers the most appropriate, safe, and cost‑effective site of service (typically the ASC when criteria are met) and directs use of hospital settings only when exceptions or higher clinical risk factors exist, or when ASC access, equipment, or privileges are not available.

    Key Definitions and Classifications

    Location where the surgical procedure is performed — Site of service
    DefinitionSite of service: location where the surgical procedure is performed (ASC, off‑campus outpatient hospital/medical center, on‑campus outpatient hospital/medical center, inpatient hospital/medical center)
    Preferred siteAmbulatory Surgical Center (ASC) is the preferred medically necessary site for certain elective surgical procedures when criteria are met
    AlternativesOff‑campus outpatient hospital/medical center; On‑campus outpatient hospital/medical center; Inpatient hospital/medical center (when criteria apply)
    An anesthesia risk category referenced as a criterion for higher-risk patients — ASA classification III or higher
    Referenced anesthesia risk categoryASA classification III or higher (used as a criterion for higher‑risk patients)
    Documentation examplesPersonal history of complication of anesthesia; substance use (alcohol dependence, cocaine) may raise anesthesia risk
    Operational implicationPatients meeting ASA III+ typically require hospital outpatient or inpatient site consideration rather than ASC
    ASA Physical Status Classification — ASA I-VI with adult examples
    Classification levelsASA I–VI physical status classifications
    ASA I (example)Normal healthy patient (healthy, non‑smoking, no or minimal alcohol use)
    ASA III (example)Severe systemic disease with substantive functional limitations; examples include poorly controlled DM/HTN, COPD, morbid obesity (BMI ≥40), ESRD on dialysis
    ASA IV–V (examples)ASA IV: severe systemic disease that is a constant threat to life (e.g., recent <3 months MI); ASA V: moribund patient not expected to survive without operation
    New York Heart Association (NYHA) Classification — NYHA Class I-IV functional classification
    NYHA Class I–IVNYHA functional classification for heart failure symptoms and activity limitation
    Class I (example)No symptoms and no limitation in ordinary physical activity
    Class II (example)Mild symptoms and slight limitation during ordinary activity
    Class III (example)Marked limitation in activity; walks short distances (20–100 m); comfortable only at rest

    Policy Revision History

    2026-06-05codes_added

    Hand Surgery section added to include carpal tunnel release techniques with CPT codes 29848 and 64721 (effective 06/05/2026 after 90-day provider notification).

    2026-04-01effective_date_change

    Policy effective date updated to 07/01/2026 for inclusion of UGI Endoscopy (2.01.533) due to operational readiness (effective date change noted 04/01/2026).

    2026-03-01interim_review

    Interim review approved 02/10/2026 with changes effective 06/05/2026, including addition of Hand Surgery CPT codes 29848 and 64721 (03/01/26 entry documenting approval and effective date).

    2026-01-01codes_added

    Cardiac Surgery section added with implantable loop recorder CPT code 33285 and HCPCS code E0616, effective April 8, 2026 (noted in 01/01/26 interim review).

    2025-12-01title_and_procedure_addition

    Title changed to include diagnostic procedures and Upper Gastrointestinal (UGI) Endoscopy (2.01.533) added to list requiring ASC site-of-service review (effective March 4, 2026 per 12/01/25 entry).

    2025-11-01shoulder_codes_added

    Added shoulder arthroscopy to ASC-eligible list and added CPT codes 23700, 29805-29807, 29819-29828 effective 02/06/2026 (noted 11/01/25 interim review).

    2025-08-01new_guidelineLatest

    New Utilization Management Guideline approved 07/08/2025 and effective for dates of service on or after 11/07/2025, establishing ASC site-of-service criteria for select surgical procedures.