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.

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.

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.

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 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.

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.