ModifiedPremera BluecrossPolicy 11.01.525

Site of Service review for ambulatory surgical center (ASC) for select elective surgical or diagnostic procedures in adults

Defines medical necessity criteria for the appropriate site of service (ASC, on-campus/out‑campus outpatient hospital, inpatient hospital) for selected elective surgical and diagnostic procedures and lists applicable CPT/HCPCS codes. Prior authorization/site-of-service review is required for listed procedures; criteria identify when ASC is preferred or when hospital setting is medically necessary.

Policy Summary

PayerPremera Bluecross

PolicySite of Service review for ambulatory surgical center (ASC) for select elective surgical or diagnostic procedures in adults

Policy CodePolicy 11.01.525

Change TypeMultiple material additions and revisions (shoulder arthroscopy, cardiac implantable loop recorder, UGI addition)

Effective Date

Next Review Date

Key ActionPrior authorization/site-of-service review is required for the listed elective surgical and diagnostic procedures to determine the medically appropriate place of service (ASC vs hospital outpatient vs inpatient).

SourceLink

POLICY UPDATE CHANGES

Added shoulder arthroscopy CPT codes 23700, 29805-29807, 29819-29828 as medically necessary in ASC when criteria met (effective 02/06/26).

Added cardiac surgery section to include implantable loop recorder surgery and codes 33285 and E0616 (effective 04/08/26).

Title changed to include diagnostic procedures and added Upper GI Endoscopy (2.01.533) to list (effective March-April-July 2026 adjustments to effective date).

Added header that site of service review does not apply to Indian Health Services (IHS) facilities (06/01/26).

Updated ASA Physical Status Classification table to include adult examples (12/01/25).

8Procedure categories listed (breast, cardiac, ENT, sleep, knee, shoulder, spinal, GI)

CPT/HCPCS codes enumerated

2026-04-08Latest material policy revision date

Policy summary and scope

Policy 11.01.525 defines site‑of‑service medical necessity criteria and requires prior authorization/site‑of‑service review to determine the medically appropriate place of service (with ASC preferred) for selected elective surgical and diagnostic procedures; it does not apply to Medicare Advantage and the site‑of‑service review does not apply to Indian Health Services (IHS) facilities.

Policy metadata

Policy Number11.01.525

PayerPremera BlueCross

SubjectSite of Service review for ambulatory surgical center (ASC) for select elective surgical or diagnostic procedures in adults

StatusMODIFIED

Latest material revision date2026-04-08

Last review date2026-06-01

Effective date(s) noteMultiple effective dates in history: 02/06/2026 (shoulder arthroscopy addition); 04/08/2026 (cardiac surgery section added); March–April–July 2026 adjustments for UGI addition with eventual July 1, 2026 effective date

Site-of-service medical necessity criteria

Site of Service Medical Necessity Criteria

Site of service for elective surgical procedures is reviewed for medical necessity; ASC is preferred when ALL of the following are met unless exceptions apply.

ALL of the following

Procedure eligibility: Procedure is one of the listed elective surgical or diagnostic procedures eligible for ASC consideration (see CPT/HCPCS code list)
Geographic/accessibility requirement: ASC is geographically accessible within 30 miles that can provide the necessary care and at which the individual's physician has privileges30 miles
If no qualifying ASC within 30 miles or no ASC with necessary equipment or physician privileges, hospital outpatient may be considered medically necessary
Patient or procedural exceptions permitting hospital outpatient or inpatient setting

Applicable CPT / HCPCS codes by procedure category

Breast Surgery / Reconstructive Breast Surgery / Reduction MammaplastyCPT

19318

Reduction mammaplasty

Cardiac Surgery / Implantable Loop Recordermixed

33285	Insertion, subcutaneous cardiac rhythm monitor, including program
E0616	Implantable cardiac event recorder with memory, activator, and programmer (HCPCS)

ENT Surgery / RhinoplastyCPT

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
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

ENT Surgery / Sinus Surgery and Nasal EndoscopyCPT

31233	Nasal endoscopy, diagnostic, unilateral or bilateral
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 including sphenoidotomy
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total 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

1–10 of 17

1/2

Sleep Apnea / Snoring SurgeryCPT

42145

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty)

Knee Surgery / Osteochondral Autograft/Allograft / ACI / Arthroscopymixed

27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (includes harvesting)
28446	Open osteochondral autograft, talus (includes obtaining grafts)
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (includes harvesting)
29867	Arthroscopy, knee, surgical; osteochondral allograft
27412	Autologous chondrocyte implantation, knee
J7330	Autologous cultured chondrocytes, implant (HCPCS/J-code)
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)
29871	Arthroscopy, knee, surgical; for infection, lavage and drainage
29873	Arthroscopy, knee, surgical; with lateral release

1–10 of 22

1/3

Shoulder Procedures / ArthroscopyCPT

23700	Manipulation under anesthesia, shoulder joint
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
29823	Arthroscopy, shoulder, surgical; debridement, extensive
29824	Arthroscopy, shoulder, surgical; distal claviculectomy (Mumford procedure)

1–10 of 14

1/2

Spinal Procedures / NeurostimulatorCPT

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
63663	Revision including replacement of spinal neurostimulator electrode percutaneous array(s)
63664	Revision including replacement of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver

Billing, prior authorization, and documentation requirements

Prior Authorization

Site-of-service prior authorization required

Prior authorization/site-of-service review is required for the listed elective surgical and diagnostic procedures to determine the medically appropriate place of service (ASC vs hospital outpatient vs inpatient).

Affected procedures: see code groups for breast, cardiac (33285, E0616), ENT (30400–30450; 31233–31298), sleep (42145), knee (27412–29889, J7330, S2112), shoulder (23700, 29805–29807, 29819–29828), spinal (63650–63688), and others listed in the policy.

Documentation Required

Document clinical exceptions and risks

Providers must document clinical conditions (ASA class, NYHA class, recent MI/CVA dates, MELD score, FEV1 values, dialysis status, BMI, bleeding disorder details, anticipated transfusion need) to justify hospital outpatient or inpatient site when ASC criteria are not met.

Key terms and classifications

Definitions

Site of ServiceLocation where the surgical procedure is performed (ASC, off-campus outpatient hospital, on-campus outpatient hospital, or inpatient hospital)

ASA Physical Status ClassificationAmerican Society of Anesthesiologists classification I–VI describing preoperative physical fitness; ASA III or higher increases site-of-service risk

NYHA ClassificationNew York Heart Association classification of heart failure severity (Class I–IV)

Policy changes and effective dates

08/01/25new_policy

New Utilization Management Guideline approved July 8, 2025; effective for dates of service on or after November 7, 2025 — Site of Service for Ambulatory Service Center (ASC) for select surgical procedures considered medically necessary when criteria are met.

11/01/25interim_review

Interim review approved October 14, 2025; effective February 6, 2026 — Added shoulder arthroscopy CPT codes 23700, 29805-29807, 29819-29828 as medically necessary in ASC when criteria met (effective 02/06/26).

12/01/25minor_update

Interim review approved November 11, 2025; minor update to ASA Physical Status Classification table to include adult examples. Title changed to include diagnostic procedures and 2.01.533 Upper GI Endoscopy added with an initial effective date of March 4, 2026.

Policy Summary

PayerPremera Bluecross

PolicySite of Service review for ambulatory surgical center (ASC) for select elective surgical or diagnostic procedures in adults

Policy CodePolicy 11.01.525

Change TypeMultiple material additions and revisions (shoulder arthroscopy, cardiac implantable loop recorder, UGI addition)

Effective Date

Next Review Date

SourceLink

On This Page

Age and concurrent service exceptions: Individual is aged 18 or younger OR service is performed with an additional service that requires hospital outpatient department and both are in same operative session
Clinical conditions that increase risk for complications (any of):
- Anesthesia risk: ASA classification III or higher; personal history of complication of anesthesia; documentation of alcohol dependence or history of cocaine use; prolonged surgery (> 3 hours)ASA III or higher; > 3 hours
  See ASA Physical Status Classification for examples
- Cardiovascular risk: Uncompensated chronic heart failure (NYHA class III or IV); recent MI (< 3 months); poorly controlled, resistant hypertension (defined as 3 or more drugs to control blood pressure); recent cerebrovascular accident (< 3 months); increased risk for cardiac ischemia (DES placed <1 year or angioplasty <90 days); symptomatic cardiac arrhythmia despite medication; significant valvular heart diseaseRecent MI < 3 months; NYHA III/IV; 3+ antihypertensives
- Liver risk: Advanced liver disease (MELD Score > 8)MELD > 8
- Pulmonary risk: Chronic obstructive pulmonary disease (COPD) with FEV1 < 50%; poorly controlled asthma with FEV1 < 80% despite treatmentFEV1 < 50% (COPD); FEV1 < 80% (asthma despite treatment)
- Renal risk: End stage renal disease (on dialysis)On dialysis
- Other risks: Morbid obesity (BMI >= 50); pregnancy; bleeding disorder requiring replacement factor, blood products, or special infusion product (DDAVP does not meet this criterion); anticipated need for transfusion(s)BMI >= 50
  DDAVP alone does not meet bleeding disorder criterion

Sites Considered

When criteria are met, the following sites are considered medically necessary in order of preference or as required by exceptions:

Sites considered (in order of preference)

Preferred site: Ambulatory surgical center (preferred when criteria met)
Alternative site 1: Off campus-outpatient hospital/medical center
Considered when ASC not available or exceptions apply
Alternative site 2: On campus-outpatient hospital/medical center
When inpatient required: Inpatient hospital/medical center (when inpatient criteria apply)

Risk thresholds

Prolonged surgery> 3 hours

ASA classificationIII or higher

MELD Score> 8

COPD FEV1< 50%

Asthma FEV1< 80% despite treatment

Morbid obesityBMI >= 50

Resistant hypertension3 or more drugs to control blood pressure

ASA class
NYHA class
Recent MI/CVA dates
MELD score
FEV1 values
Dialysis status
BMI
Bleeding disorder details (need for replacement factor, blood products, or special infusion product)
Anticipated transfusion need

Billing Rule

Place of service coding

Report appropriate Place of Service professional claim codes for the site where the procedure is performed.

19: Off-Campus-Outpatient Hospital (Off-Campus-Outpatient Hospital)
21: Inpatient Hospital (Inpatient Hospital)
22: On Campus-Outpatient Hospital (On Campus-Outpatient Hospital)
24: Ambulatory Surgical Center (Ambulatory Surgical Center)

01/01/26interim_review

Interim review approved December 23, 2025 — Added new Cardiac Surgery section to include implantable loop recorder surgery and added CPT code 33285 and HCPCS code E0616; added policy 2.02.510 Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders.

03/04/26 to 07/01/26revised_effective_date

Multiple interim reviews adjusted the effective date for adding Upper GI Endoscopy (2.01.533) due to operational readiness: originally effective March 4, 2026, updated to May 1, 2026, then updated to July 1, 2026 (final effective date 07/01/26).

04/08/26material_changeLatest

Material policy change effective April 8, 2026 — Added cardiac surgery section to include implantable loop recorder surgery and codes 33285 and E0616; related policy 2.02.510 added.

06/01/26minor_update

Minor update — Added header that site of service review does not apply to Indian Health Services (IHS) facilities (06/01/26).