ModifiedPremera BluecrossPolicy N/A

Site-of-service prior authorization for Select Surgical or Diagnostic Procedures in Adults

Defines medical necessity criteria and required site-of-service review for specified elective surgical procedures and the circumstances in which ambulatory surgical center (ASC), hospital outpatient, or inpatient settings are appropriate for Premera members and their providers.

Policy Summary

PayerPremera Bluecross

PolicySite-of-service prior authorization for Select Surgical or Diagnostic Procedures in Adults

Policy CodePolicy N/A

Change TypeRevised — scope expanded and CPT/HCPCS lists updated

Effective DateMultiple effective dates (see history); latest changes effective Jun 5, 2026

Next Review DateN/A

Key ActionObtain prior authorization for the site of service for listed elective surgical and diagnostic procedures; document clinical justification when choosing a non-ASC site.

SourceLink

POLICY UPDATE CHANGES

This policy has been revised.

Title changed to include diagnostic procedures and broaden scope to 'Select Surgical or Diagnostic Procedures in Adults'.

Added Upper Gastrointestinal (UGI) Endoscopy in Adults to procedures requiring review for ASC site of service.

Added cardiac surgery section including implantable loop recorder surgery with CPT 33285 and HCPCS E0616.

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

Added multiple CPT codes (e.g., 23700, 29805-29807, 29819-29828) to ASC-appropriate procedures.

Multipleprocedure categories

MultipleCPT codes added

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30 migeographic access

ASA III+ASA referenced

Site-of-Service Coverage Criteria

Medical necessity criteria for site of service

Covered when ALL of the following are met

Site selection for elective surgeries: The procedure is an elective surgical procedure listed in the policy and the selected site is the most appropriate, safe, and cost-effective given the individual's clinical factors and service needs.

Preferred site is ASC when criteria allow

ASC as preferred medically necessary site: Ambulatory surgical center is the preferred medically necessary site for certain elective surgical procedures when no exclusion criteria are present.

When hospital outpatient is medically necessary: An elective procedure performed in a hospital outpatient department may be considered medically necessary if (1) no qualifying ASC within 30 miles that can provide the necessary care or where the physician has privileges, (2) the individual is aged 18 or younger, (3) the service is performed in conjunction with an additional service that requires hospital outpatient department in the same operative session, or (4) the individual has clinical conditions that increase risk for complications (see risk list).30 miles

Providers must document justification for non-ASC site when these criteria apply

Clinical risk factors requiring higher-acuity site: Clinical conditions include: ASA classification III or higher; personal history of anesthesia complication; documentation of alcohol dependence or history of cocaine use; prolonged surgery (>3 hours); cardiovascular risks (uncompensated CHF NYHA class III or IV; recent MI <3 months; poorly controlled/resistant hypertension; recent CVA <3 months; increased risk for cardiac ischemia such as drug-eluting stent <1 year or angioplasty <90 days; symptomatic arrhythmia despite medication; significant valvular heart disease); liver risk (MELD >8); pulmonary risk (COPD with FEV1 <50%; poorly controlled asthma with FEV1 <80% despite treatment; moderate–severe OSA); renal risk (end stage renal disease on dialysis); morbid obesity (BMI ≥50); pregnancy; bleeding disorder requiring replacement products (DDAVP does not meet this criterion); anticipated need for transfusion(s).various clinical thresholds listed

List may not be all inclusive; see ASA and NYHA definitions for examples

ASC medical necessity (general)

Site of Service for Ambulatory Service Center (ASC) for Select Surgical or Diagnostic Procedures will be considered medically necessary when criteria are met.

ASC medical necessity general statement: ASC site-of-service will be considered medically necessary for select surgical or diagnostic procedures when the policy's criteria are satisfied.

Specific per-procedure criteria, related policy references, and procedure code lists apply (see history and coding sections).

Off‑campus outpatient hospital/medical center and on‑campus outpatient hospital/medical center sites of service are not medically necessary for certain elective surgical procedures when the policy's site‑of‑service criteria are not met. Examples of clinical risk factors that may require a higher‑acuity site and therefore make outpatient hospital use appropriate include: morbid obesity (BMI ≥50), pregnancy, bleeding disorders requiring replacement products (note: DDAVP does not meet this criterion), and an anticipated need for transfusion(s). When these or other listed clinical exceptions are present, hospital outpatient settings may be considered; otherwise off‑campus and on‑campus outpatient hospital locations are not considered medically necessary for the elective procedures listed in this policy.

Inpatient hospital/medical center care for the elective surgical procedures covered by this policy is not medically necessary unless the patient meets listed clinical risk or service factors that require inpatient care. The policy specifies that inpatient admission is only appropriate when clinical conditions or concurrent service needs (for example those that cannot be safely managed in ambulatory or outpatient settings) indicate a medically necessary inpatient level of care.

This medical policy does not apply to Medicare Advantage. Historical and administrative updates to the policy (including title and scope changes) are documented in the policy history; the Medicare Advantage exclusion is noted in the policy administrative scope.

Use of hospital outpatient or inpatient settings for elective surgical procedures is not medically necessary when an Ambulatory Surgical Center (ASC) is accessible and none of the policy's listed clinical or service‑based exceptions apply. Providers should select ASC as the preferred site when the procedure and the patient meet the policy criteria and no exclusion (such as those clinical risk factors that necessitate higher‑acuity care) is present.

Procedures or sites of service that do not meet the policy criteria for ASC site‑of‑service review are considered not ASC‑appropriate and may be subject to denial. The policy history documents additions of specific CPT/HCPCS codes (for example, implantable loop recorder codes and multiple shoulder/carpal tunnel codes) that require ASC site‑of‑service review; services not meeting the review criteria or lacking supporting clinical justification should be billed and reviewed at an appropriate higher‑acuity site.

Procedures, Codes, and Risk Classification

Covered CPT/HCPCS Codes listed by specialtymixedCovered

19318	Reduction mammaplasty
33285	Insertion, subcutaneous cardiac rhythm monitor, including program
E0616	Implantable cardiac event recorder with memory, activator, and programmer
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)
31233	Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

1–10 of 73

1/8

Place of Service (Professional Claims Codes)Revenue

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

Select CPT Codes added to ASC proceduresCPTCovered

23700	CPT code added to ASC procedures list
29805	CPT code added to ASC procedures list
29806	CPT code added to ASC procedures list
29807	CPT code added to ASC procedures list
29819	CPT code added to ASC procedures list
29820	CPT code added to ASC procedures list
29821	CPT code added to ASC procedures list
29822	CPT code added to ASC procedures list
29823	CPT code added to ASC procedures list
29824	CPT code added to ASC procedures list

1–10 of 17

1/2

Select HCPCS CodesHCPCSCovered

E0616

HCPCS code related to implantable loop recorder

inv-12: BMI threshold for morbid obesity — numeric threshold used as risk factor

BMI threshold for morbid obesityBMI greater than or equal to 50

ContextMorbid obesity listed as a clinical condition that increases risk for complications and may necessitate higher-acuity site selection

ImplicationBMI ≥50 is a risk factor that supports use of hospital outpatient or inpatient setting instead of ASC

inv-13: ASA classification — ASA III or higher considered increased anesthesia risk

ASA risk thresholdASA classification III or higher is considered increased anesthesia risk

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the site-of-service determination for the elective surgical and diagnostic procedures listed in this policy. Providers must obtain site-of-service prior authorization before scheduling the procedure when the planned site is anything other than an ambulatory surgical center (ASC) or when the procedure is one of the listed CPT/HCPCS codes that require ASC review.

Prior authorization required for ASC site-of-service review for listed elective procedures
Include planned site of service and procedure codes on the authorization request

Documentation Required

Required documentation to justify non-ASC site

When an ASC is not used or not available, providers must document clinical justification supporting the use of a non-ASC site of service. Documentation should demonstrate why an ASC was not accessible or appropriate and reference one or more of the allowable reasons in policy (geographic access, physician privileges, ASC-specific guidelines, patient age, concurrent services requiring hospital outpatient setting, or clinical risk factors).

Background and Rationale

Elective surgical procedures may be safely performed in multiple settings — Ambulatory Surgical Centers (ASC), off‑campus outpatient hospitals, on‑campus outpatient hospitals, or inpatient hospitals. Site selection should balance patient safety and cost‑effectiveness: ASCs are the preferred site when the procedure and the patient's clinical status meet the policy criteria, while hospital outpatient or inpatient settings are reserved for situations where geographic access, age (e.g., patients ≤18), concurrent services, or specific clinical risk factors (see policy) necessitate higher‑acuity care.

Key Definitions and Risk Scales

inv-25: Definition of site of service — location where the surgical procedure is performed (ASC, off-campus outpatient, on-campus outpatient, inpatient)

DefinitionSite of service = the 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)

Preferred siteAmbulatory surgical center (ASC) is the preferred medically necessary site for certain elective surgical procedures when criteria are met

When hospital outpatient may be usedHospital outpatient may be medically necessary if no qualifying ASC within 30 miles, patient ≤18 years, additional concurrent service requires hospital outpatient department, or specific clinical risk factors

inv-26: ASA Physical Status Classification — anesthesiology risk scale (I–VI) used to assess perioperative anesthesia risk

DefinitionASA Physical Status Classification — anesthesiology risk scale (I–VI) used to assess perioperative anesthesia risk

Policy Summary

PayerPremera Bluecross

PolicySite-of-service prior authorization for Select Surgical or Diagnostic Procedures in Adults

Policy CodePolicy N/A

Change TypeRevised — scope expanded and CPT/HCPCS lists updated

Effective DateMultiple effective dates (see history); latest changes effective Jun 5, 2026

Next Review DateN/A

Key ActionObtain prior authorization for the site of service for listed elective surgical and diagnostic procedures; document clinical justification when choosing a non-ASC site.

SourceLink

On This Page

ASA Physical Status Classification (I–VI) used to assess perioperative anesthesia risk

ExamplesASA III examples include morbid obesity (BMI ≥40), poorly controlled DM/HTN, COPD, ESRD on dialysis

inv-14: NYHA — NYHA class III or IV = uncompensated chronic heart failure (increased cardiovascular risk)

NYHA risk thresholdNYHA class III or IV (uncompensated chronic heart failure) denotes increased cardiovascular risk

Clinical implicationUncompensated CHF (NYHA III/IV) is listed among conditions that may require hospital outpatient or inpatient care rather than ASC

SourceNew York Heart Association (NYHA) Classification

inv-15: NYHA Class examples — Class III and Class IV functional examples

NYHA Class III exampleMarked limitation in activity due to symptoms during less-than-ordinary activity (e.g., walking short distances 20–100 m); comfortable only at rest

NYHA Class IV exampleSevere limitations with symptoms at rest; mostly bedbound patients

PurposeThese examples illustrate functional severity used to determine cardiovascular risk for site-of-service decisions

Document why no qualifying ASC is available within 30 miles OR why the ASC cannot provide necessary equipment or lacks physician privileges
If ASC guidelines prohibit the case (for example due to weight or specific health conditions), include the ASC guideline or statement
If patient is aged 18 or younger, document age and rationale for hospital-based site
If procedure is performed with another service requiring hospital outpatient department during same operative session, include documentation of the concurrent service

Documentation Required

Supporting documentation for ASC site-of-service

When requesting ASC site-of-service review, include supporting clinical documentation demonstrating the medical necessity of the ASC (or of an alternative site when applicable). This should include relevant procedure-specific notes, related policy references, and objective clinical risk assessments.

Operative/consultation notes describing indication for procedure and planned surgical approach
Relevant prior authorization or medical record documenting attempts to schedule at an ASC (scheduling logs, ASC responses)
If clinical risk is cited, include objective data such as ASA classification, NYHA class, MELD score, FEV1, BMI, history of anesthesia complications, recent MI/CVA dates, dialysis status, or bleeding disorder documentation
Include related policy or procedure references when applicable (e.g., reconstructive breast surgery, carpal tunnel release, implantable loop recorder policy 2.02.510)
For implantable loop recorder procedures, include device-specific documentation (e.g., indication, prior noninvasive monitoring results) and the CPT/HCPCS code submitted (e.g., CPT 33285, HCPCS E0616)

Note

Provider Actions — general

Providers should take the following actions to minimize denials and ensure timely review: submit a complete prior authorization request with all required supporting documentation; clearly indicate the requested site of service and rationale; and attach relevant clinical data and related policy references.

Include CPT/HCPCS codes, planned site of service, and expected anesthesia requirements on the request
Attach pertinent clinical records (office notes, diagnostic testing, anesthesia evaluation) at time of submission
If asserting lack of ASC access, provide evidence (within 30-mile radius) such as communications with ASCs or scheduling records
When clinical risk factors are present, include objective measures (ASA, NYHA, BMI, MELD, FEV1, recent MI/CVA dates, dialysis status)

Note

Provider Actions — additional

Additional provider actions specific to ASC determinations and newly added procedure codes: verify whether the CPT/HCPCS code is on the list requiring ASC site-of-service review and obtain authorization accordingly. For any added or newly reviewed procedures (for example implantable loop recorder insertion CPT 33285, HCPCS E0616), include device and indication documentation and reference related policies.

Confirm code-specific review requirement prior to scheduling (e.g., CPT 33285, HCPCS E0616 now require ASC site review)
For procedures added during policy updates (see History), include related policy numbers or prior authorization references to expedite review
If surgery will be performed in an ASC but patient has risk factors, provide perioperative risk evidence to support ASC safety

Denial Risk

Denial triggers for inappropriate site of service

A site-of-service determination may be denied when documentation is insufficient or the clinical circumstances do not meet policy criteria for a non-ASC site. Common denial triggers include failure to provide evidence of ASC unavailability within 30 miles, absence of physician privilege or ASC equipment documentation, lack of objective clinical risk data when claiming increased complication risk, or when the requested hospital-based site is not supported by concurrent services or age-based criteria.

No documentation that no qualifying ASC exists within 30 miles or that ASC cannot provide the procedure
No evidence of physician privileges at available ASCs when used as justification
No ASC guideline or statement when ASC-specific restrictions are cited
Insufficient objective clinical data to support ASA III+, NYHA III/IV, MELD >8, FEV1 thresholds, BMI >=50, recent MI/CVA timeframes, dialysis status, or bleeding disorder criteria
Requesting inpatient or hospital outpatient site solely for provider convenience or cost reasons without clinical justification

Denial Risk

Denial risk for ASC site-of-service determinations

When procedures or codes do not meet the ASC site-of-service criteria and there is no supporting related policy that justifies a hospital-based site, the authorization request is at increased risk of denial. Providers should ensure all applicable policy criteria and supporting documentation are provided to mitigate this risk.

ASC site-of-service denials may occur if procedure is not on the approved list or if supporting related policy is not cited
Verify related policies listed in the policy document (e.g., reconstructive breast surgery, carpal tunnel release, mobile cardiac outpatient telemetry) and include those references

PurposeUsed to identify individuals with increased anesthesia risk (ASA III or higher) influencing site-of-service selection

Source noteTable includes adult examples and common comorbidity abbreviations (e.g., DM, HTN, COPD, ESRD)

inv-27: NYHA Classification — heart failure functional classification used to gauge cardiovascular risk

DefinitionNYHA Classification — heart failure functional classification used to gauge cardiovascular risk

ClassesFour-class system from Class I (no symptoms) to Class IV (symptoms at rest)

Use in policyNYHA class III or IV (uncompensated CHF) listed as a cardiovascular risk factor that may necessitate higher-acuity site selection

inv-28: ASA Physical Status Classification — American Society of Anesthesiologists (ASA) classification table reference

SourceAmerican Society of Anesthesiologists (ASA) Physical Status Classification table

Content summaryDescribes ASA I–VI with adult examples (e.g., ASA III: severe systemic disease with substantive functional limitations; ASA IV: severe disease that is a constant threat to life)

ReferenceStatement on ASA Physical Status Classification System; adult examples include morbid obesity (BMI ≥40), ESRD on dialysis, recent MI/CVA >3 months, etc.

inv-29: NYHA Classification — New York Heart Association (NYHA) classification table reference

SourceNew York Heart Association (NYHA) Classification table

Class descriptionsClass I: no symptoms; Class II: mild symptoms with slight limitation; Class III: marked limitation (walking short distances 20–100 m); Class IV: symptoms at rest, mostly bedbound

UseTable used to identify uncompensated chronic heart failure (NYHA III/IV) as a cardiovascular risk in site-of-service determinations