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ModifiedPremera BluecrossPolicy 11.01.525

Site of Service Ambulatory Service Center (ASC) Select

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

Policy Summary

PayerPremera Bluecross

PolicySite of Service Ambulatory Service Center (ASC) Select

Policy CodePolicy Policy 11.01.525

Change TypeRevision effective Sep 1, 2026

Effective DateSep 1, 202613d

Last ReviewJun 16, 2026

Next Review DateSep 1, 202613d

Key ActionPrior authorization is required for the site of service for the listed elective ambulatory surgical procedures.

SourceLink

POLICY UPDATE CHANGES

This policy has been revised with changes effective September 1, 2026.

MultipleProcedure groups listed

≤18Pediatric exception age

30 milesASC accessibility

ASA III+Anesthesia risk

>3 hrProlonged surgery threshold

MultiplePolicy history

Medical Necessity Criteria for Site of Service

Site of Service Medical Necessity Criteria

Covered when ALL of the following rules for site selection are satisfied:

Ambulatory surgical center (ASC) is the preferred medically necessary site of service for certain elective surgical procedures when criteria are met.

Exceptions permitting hospital outpatient setting

There is no qualifying ASC within 30 miles that can provide the necessary care.
There is no geographically accessible ASC that has the necessary equipment to perform the procedure.
There is no geographically accessible ASC available at which the individual's physician has privileges.

Patient / procedural exceptions requiring hospital setting

The individual is aged 18 years or younger.
The service is performed in conjunction with an additional service that requires use of a hospital outpatient department and both procedures are being performed in the same operative session.
Clinical conditions increasing risk
- Anesthesia risk: ASA classification III or higher.
- Anesthesia risk: personal history of complication of anesthesia.
- Anesthesia risk: documentation of alcohol dependence or history of cocaine use.
- Anesthesia risk: prolonged surgery duration greater than 3 hours.
- Cardiovascular risk: uncompensated chronic heart failure (NYHA class III or IV).
- Cardiovascular risk: recent myocardial infarction within the past 3 months.
- Cardiovascular risk: poorly controlled, resistant hypertension (eg, requiring 3 or more drugs).
- Cardiovascular risk: recent cerebrovascular accident within the past 3 months.
- Cardiovascular risk: increased risk for cardiac ischemia (drug-eluting stent placed <1 year or angioplasty <90 days).
- Cardiovascular risk: symptomatic cardiac arrhythmia despite medication.
- Cardiovascular risk: significant valvular heart disease.
- Liver risk: advanced liver disease (MELD score greater than 8).
- Pulmonary risk: COPD with FEV1 < 50%.
- Pulmonary risk: poorly controlled asthma (FEV1 < 80% despite treatment).
- Renal risk: end-stage renal disease on dialysis.
- Other: morbid obesity (BMI ≥ 50).
- Other: pregnancy.
- Other: bleeding disorder requiring replacement factor, blood products, or special infusion product (DDAVP does not meet this criterion).
- Other: anticipated need for transfusion(s).

If the site-of-service criteria above are not met, on-campus outpatient, off-campus outpatient, and inpatient hospital sites are considered not medically necessary for the elective procedures covered by this guideline.

This guideline applies to the listed elective surgical procedures across multiple specialties; refer to individual procedure policies for procedure-specific medical necessity criteria.

ASC site-of-service coverage criteria (summary)

Considered medically necessary when ALL of the following are true:

Site of Service for Ambulatory Surgical Center (ASC) for select surgical or diagnostic procedures is supported when the policy's site-of-service criteria are met.

Specific procedures added to the policy (for example, shoulder arthroscopy, upper GI endoscopy, implantable loop recorder insertion, carpal tunnel release) require site-of-service review and are eligible for ASC when applicable criteria are satisfied.

Policy applicability and procedure additions are documented in the policy history; this guideline does not apply to Medicare Advantage plans.

Procedure Codes and Operational Thresholds

Example CPT codes by specialtyCPT

29871-29883, 29884, 29888-29889	Knee arthroscopy and related knee procedure CPT codes referenced
27415-27416, 27412	Knee osteochondral graft and autologous chondrocyte implantation codes
29805-29828	Shoulder arthroscopy and related shoulder procedure CPT codes referenced
63650-63688	Spinal neurostimulator and related CPT codes

CPT codes added in historyCPT

33285	Implantable loop recorder insertion (added)
29805-29807, 29819-29828, 23700	Shoulder arthroscopy CPT codes (added)
29848, 64721	Hand surgery / carpal tunnel release codes (added)

Prolonged surgery duration — threshold (> 3 hours)

Operational threshold for prolonged surgeryProlonged surgery greater than 3 hours

Context where appliedUsed as an anesthesia-related risk factor supporting hospital outpatient setting instead of ASC

Related policy noteListed among clinical conditions that increase risk for complications (ASA III+, prolonged surgery >3 hours, etc.)

Morbid obesity BMI threshold (high risk) — BMI ≥ 50

Morbid obesity BMI threshold (high risk)BMI ≥ 50

Related mention in ASA examplesASA examples reference morbid obesity (BMI ≥40) as an example of substantive limitation; policy uses BMI ≥50 as high-risk threshold

ImplicationMeets clinical risk criteria to consider hospital outpatient setting instead of ASC

Advanced liver disease MELD score — MELD > 8

Advanced liver disease thresholdMELD score greater than 8

CategoryListed under liver risk as a clinical condition that increases risk for complications

ImplicationSupports selection of hospital outpatient setting rather than ASC when present

Prior Authorization, Denial Risk, and Site-of-Service Operations

Prior Authorization

Prior authorization required for site-of-service review

Prior authorization is required for the site of service for the listed elective ambulatory surgical and diagnostic procedures; submit site-of-service review requests through the payer's prior authorization process so Premera can determine medical necessity for ASC versus hospital settings.

Prior authorization is required to determine the most appropriate, safe, and cost-effective site of service.
Request prior authorization via Premera's standard prior authorization/submission channels for site-of-service review.

Denial Risk

Denial risk and permitted exceptions for hospital outpatient site

An outpatient hospital department may be considered medically necessary instead of an ASC when specific exceptions apply; failure to document an applicable exception may result in denial of ASC-to-hospital site requests.

Geographic/access exception: no qualifying ASC within 30 miles that has necessary equipment or where the physician has privileges (document the lack of accessible ASC).
Clinical/patient exceptions include: age ≤18, concurrent procedure requiring hospital outpatient department, ASA III+ or other listed high-risk conditions (e.g., prolonged surgery >3 hours, recent MI <3 months, NYHA III/IV CHF, MELD >8, ESRD on dialysis, BMI ≥50).
If an applicable exception is not documented, authorization for hospital outpatient site may be denied.

Note

ASC considered medically necessary when criteria are met

Site of Service in an Ambulatory Surgical Center (ASC) will be considered medically necessary when the policy's site-of-service medical necessity criteria are met.

ASC is the preferred medically necessary site for certain elective surgical or diagnostic procedures when criteria are satisfied.
Site-of-service determinations will follow the policy's listed clinical and access criteria.

Documentation Required

Procedure additions in policy history require site-of-service review

Procedures and CPT codes added in the policy history (e.g., UGI endoscopy, shoulder arthroscopy, implantable loop recorder, carpal tunnel release and listed CPTs) require site-of-service review under this guideline when the policy criteria apply.

Policy history documents additions and effective dates for specific procedures and CPT codes; providers must request site-of-service review for those listed procedures.
Examples of added CPTs include 33285, 29805-29807, 29819-29828, 23700, 29848, and 64721 (see history entries for effective dates).

Clinical Classifications and Codes

ASA physical status — overview and examples

Purpose of ASA PSClassification system to assess anesthesia risk and guide site-of-service decisions

StructureSix-category system (ASA I–VI) describing increasing severity of systemic disease and perioperative risk

Examples providedIncludes adult example conditions (e.g., controlled DM/HTN, COPD, morbid obesity) to illustrate categories

ASA Physical Status (ASA I–VI) — adult examples

ASA IA normal healthy patient (no systemic disease)

ASA IIPatient with mild systemic disease without substantive functional limitations (e.g., controlled DM or HTN, mild lung disease)

ASA IIIPatient with severe systemic disease with substantive functional limitations (e.g., poorly controlled DM or HTN, COPD, morbid obesity)

ASA IVPatient with severe systemic disease that is a constant threat to life (e.g., scheduled dialysis, recent or ongoing severe cardiac or systemic conditions)

ASA VA moribund patient who is not expected to survive without the operation (e.g., massive trauma, ruptured aneurysm)

ASA VIA declared brain-dead patient whose organs are being removed for donor purposes

Abbreviations used in ASA examples

DMDiabetes mellitus

HTNHypertension

COPDChronic obstructive pulmonary disease

ESRDEnd stage renal disease

MIMyocardial infarction

CVACerebral vascular accident (stroke)

TIATransient ischemic attack

New York Heart Association (NYHA) Classification I–IV

NYHA Class INo symptoms and no limitation in ordinary physical activity

NYHA Class IIMild symptoms and slight limitation during ordinary activity

NYHA Class IIIMarked limitation in activity; comfortable only at rest (e.g., limited walking short distances)

NYHA Class IVSevere limitations; symptoms at rest; mostly bedbound

Place of Service (Professional claim codes)

Place of Service 19Off-Campus-Outpatient Hospital

Place of Service 21Inpatient Hospital

Place of Service 22On Campus-Outpatient Hospital

Place of Service 24Ambulatory Surgical Center (ASC)

Policy Changes and Effective Dates

2026-09-01policy_effective_dateLatest

Policy revision with changes effective September 1, 2026, updating the effective date for UGI endoscopy site-of-service review and other history amendments.

2026-06-16policy_update

Policy effective date updated from July 1, 2026 to September 1, 2026 for 2.01.533 Upper Gastrointestinal (UGI) Endoscopy in Adults requiring site-of-service review.

2026-06-05interim_review_effective

Interim review approved February 10, 2026 with changes effective June 5, 2026, adding Hand Surgery section including carpal tunnel release and CPT codes 29848 and 64721.

2026-04-08interim_review_effective

Interim review approved December 23, 2025 with changes effective April 8, 2026, adding Cardiac Surgery section including implantable loop recorder CPT code 33285.

2026-03-04interim_review_effective

Interim review approved November 11, 2025 with changes effective March 4, 2026, retitled policy to include diagnostic procedures and added Upper Gastrointestinal (UGI) Endoscopy to procedures requiring site-of-service review.

2026-02-06interim_review_effective

Interim review approved October 14, 2025 with changes effective February 6, 2026, adding shoulder arthroscopy to ASC-select procedures and adding CPT codes 23700, 29805-29807, 29819-29828.

2025-11-07new_guideline_effective

New Utilization Management Guideline approved July 8, 2025 became effective November 7, 2025; established ASC site-of-service medical necessity criteria for select procedures.

Policy Summary

PayerPremera Bluecross

PolicySite of Service Ambulatory Service Center (ASC) Select

Policy CodePolicy Policy 11.01.525

Change TypeRevision effective Sep 1, 2026

Effective DateSep 1, 202613d

Last ReviewJun 16, 2026

Next Review DateSep 1, 202613d

Key ActionPrior authorization is required for the site of service for the listed elective ambulatory surgical procedures.

SourceLink

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Site of Service Ambulatory Service Center (ASC) Select

Customize your policy alerts

Sign up for Premera Bluecross Policy 11.01.525 alerts

Get alerted when Policy 11.01.525 changes without checking for updates manually.

We'll notify you when Premera Bluecross policy Policy 11.01.525 is updated.

Monitor payer policy activity

We'll watch this exact policy and email you whenever it changes.

Medical Necessity Criteria for Site of Service

Site of Service Medical Necessity Criteria

Covered when ALL of the following rules for site selection are satisfied:

Ambulatory surgical center (ASC) is the preferred medically necessary site of service for certain elective surgical procedures when criteria are met.

Exceptions permitting hospital outpatient setting

There is no qualifying ASC within 30 miles that can provide the necessary care.
There is no geographically accessible ASC that has the necessary equipment to perform the procedure.
There is no geographically accessible ASC available at which the individual's physician has privileges.

Patient / procedural exceptions requiring hospital setting

The individual is aged 18 years or younger.
The service is performed in conjunction with an additional service that requires use of a hospital outpatient department and both procedures are being performed in the same operative session.
Clinical conditions increasing risk
- Anesthesia risk: ASA classification III or higher.
- Anesthesia risk: personal history of complication of anesthesia.
- Anesthesia risk: documentation of alcohol dependence or history of cocaine use.
- Anesthesia risk: prolonged surgery duration greater than 3 hours.
- Cardiovascular risk: uncompensated chronic heart failure (NYHA class III or IV).
- Cardiovascular risk: recent myocardial infarction within the past 3 months.
- Cardiovascular risk: poorly controlled, resistant hypertension (eg, requiring 3 or more drugs).
- Cardiovascular risk: recent cerebrovascular accident within the past 3 months.
- Cardiovascular risk: increased risk for cardiac ischemia (drug-eluting stent placed <1 year or angioplasty <90 days).
- Cardiovascular risk: symptomatic cardiac arrhythmia despite medication.
- Cardiovascular risk: significant valvular heart disease.
- Liver risk: advanced liver disease (MELD score greater than 8).
- Pulmonary risk: COPD with FEV1 < 50%.
- Pulmonary risk: poorly controlled asthma (FEV1 < 80% despite treatment).
- Renal risk: end-stage renal disease on dialysis.
- Other: morbid obesity (BMI ≥ 50).
- Other: pregnancy.
- Other: bleeding disorder requiring replacement factor, blood products, or special infusion product (DDAVP does not meet this criterion).
- Other: anticipated need for transfusion(s).

This guideline applies to the listed elective surgical procedures across multiple specialties; refer to individual procedure policies for procedure-specific medical necessity criteria.

ASC site-of-service coverage criteria (summary)

Considered medically necessary when ALL of the following are true:

Site of Service for Ambulatory Surgical Center (ASC) for select surgical or diagnostic procedures is supported when the policy's site-of-service criteria are met.

Policy applicability and procedure additions are documented in the policy history; this guideline does not apply to Medicare Advantage plans.

Procedure Codes and Operational Thresholds

Example CPT codes by specialtyCPT

29871-29883, 29884, 29888-29889	Knee arthroscopy and related knee procedure CPT codes referenced
27415-27416, 27412	Knee osteochondral graft and autologous chondrocyte implantation codes
29805-29828	Shoulder arthroscopy and related shoulder procedure CPT codes referenced
63650-63688	Spinal neurostimulator and related CPT codes

CPT codes added in historyCPT

33285	Implantable loop recorder insertion (added)
29805-29807, 29819-29828, 23700	Shoulder arthroscopy CPT codes (added)
29848, 64721	Hand surgery / carpal tunnel release codes (added)

Prolonged surgery duration — threshold (> 3 hours)

Operational threshold for prolonged surgeryProlonged surgery greater than 3 hours

Context where appliedUsed as an anesthesia-related risk factor supporting hospital outpatient setting instead of ASC

Related policy noteListed among clinical conditions that increase risk for complications (ASA III+, prolonged surgery >3 hours, etc.)

Morbid obesity BMI threshold (high risk) — BMI ≥ 50

Morbid obesity BMI threshold (high risk)BMI ≥ 50

Related mention in ASA examplesASA examples reference morbid obesity (BMI ≥40) as an example of substantive limitation; policy uses BMI ≥50 as high-risk threshold

ImplicationMeets clinical risk criteria to consider hospital outpatient setting instead of ASC

Advanced liver disease MELD score — MELD > 8

Advanced liver disease thresholdMELD score greater than 8

CategoryListed under liver risk as a clinical condition that increases risk for complications

ImplicationSupports selection of hospital outpatient setting rather than ASC when present

Prior Authorization, Denial Risk, and Site-of-Service Operations

Prior Authorization

Prior authorization required for site-of-service review

Prior authorization is required to determine the most appropriate, safe, and cost-effective site of service.
Request prior authorization via Premera's standard prior authorization/submission channels for site-of-service review.

Denial Risk

Denial risk and permitted exceptions for hospital outpatient site

Geographic/access exception: no qualifying ASC within 30 miles that has necessary equipment or where the physician has privileges (document the lack of accessible ASC).
Clinical/patient exceptions include: age ≤18, concurrent procedure requiring hospital outpatient department, ASA III+ or other listed high-risk conditions (e.g., prolonged surgery >3 hours, recent MI <3 months, NYHA III/IV CHF, MELD >8, ESRD on dialysis, BMI ≥50).
If an applicable exception is not documented, authorization for hospital outpatient site may be denied.

Note

ASC considered medically necessary when criteria are met

Site of Service in an Ambulatory Surgical Center (ASC) will be considered medically necessary when the policy's site-of-service medical necessity criteria are met.

ASC is the preferred medically necessary site for certain elective surgical or diagnostic procedures when criteria are satisfied.
Site-of-service determinations will follow the policy's listed clinical and access criteria.

Documentation Required

Procedure additions in policy history require site-of-service review

Policy history documents additions and effective dates for specific procedures and CPT codes; providers must request site-of-service review for those listed procedures.
Examples of added CPTs include 33285, 29805-29807, 29819-29828, 23700, 29848, and 64721 (see history entries for effective dates).

Clinical Classifications and Codes

ASA physical status — overview and examples

Purpose of ASA PSClassification system to assess anesthesia risk and guide site-of-service decisions

StructureSix-category system (ASA I–VI) describing increasing severity of systemic disease and perioperative risk

Examples providedIncludes adult example conditions (e.g., controlled DM/HTN, COPD, morbid obesity) to illustrate categories

ASA Physical Status (ASA I–VI) — adult examples

ASA IA normal healthy patient (no systemic disease)

ASA IIPatient with mild systemic disease without substantive functional limitations (e.g., controlled DM or HTN, mild lung disease)

ASA IIIPatient with severe systemic disease with substantive functional limitations (e.g., poorly controlled DM or HTN, COPD, morbid obesity)

ASA IVPatient with severe systemic disease that is a constant threat to life (e.g., scheduled dialysis, recent or ongoing severe cardiac or systemic conditions)

ASA VA moribund patient who is not expected to survive without the operation (e.g., massive trauma, ruptured aneurysm)

ASA VIA declared brain-dead patient whose organs are being removed for donor purposes

Abbreviations used in ASA examples

DMDiabetes mellitus

HTNHypertension

COPDChronic obstructive pulmonary disease

ESRDEnd stage renal disease

MIMyocardial infarction

CVACerebral vascular accident (stroke)

TIATransient ischemic attack

New York Heart Association (NYHA) Classification I–IV

NYHA Class INo symptoms and no limitation in ordinary physical activity

NYHA Class IIMild symptoms and slight limitation during ordinary activity

NYHA Class IIIMarked limitation in activity; comfortable only at rest (e.g., limited walking short distances)

NYHA Class IVSevere limitations; symptoms at rest; mostly bedbound

Place of Service (Professional claim codes)

Place of Service 19Off-Campus-Outpatient Hospital

Place of Service 21Inpatient Hospital

Place of Service 22On Campus-Outpatient Hospital

Place of Service 24Ambulatory Surgical Center (ASC)

Policy Changes and Effective Dates

2026-09-01policy_effective_dateLatest

Policy revision with changes effective September 1, 2026, updating the effective date for UGI endoscopy site-of-service review and other history amendments.

2026-06-16policy_update

Policy effective date updated from July 1, 2026 to September 1, 2026 for 2.01.533 Upper Gastrointestinal (UGI) Endoscopy in Adults requiring site-of-service review.

2026-06-05interim_review_effective

Interim review approved February 10, 2026 with changes effective June 5, 2026, adding Hand Surgery section including carpal tunnel release and CPT codes 29848 and 64721.

2026-04-08interim_review_effective

Interim review approved December 23, 2025 with changes effective April 8, 2026, adding Cardiac Surgery section including implantable loop recorder CPT code 33285.

2026-03-04interim_review_effective

2026-02-06interim_review_effective

Interim review approved October 14, 2025 with changes effective February 6, 2026, adding shoulder arthroscopy to ASC-select procedures and adding CPT codes 23700, 29805-29807, 29819-29828.

2025-11-07new_guideline_effective

New Utilization Management Guideline approved July 8, 2025 became effective November 7, 2025; established ASC site-of-service medical necessity criteria for select procedures.