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Site of Service Ambulatory Service Center (ASC) Select — Surgical or Diagnostic Procedures in Adults
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Defines medical necessity and prior authorization expectations for choice of site of service (ambulatory surgical center, hospital outpatient departments, inpatient) for certain elective surgical and diagnostic procedures and lists included procedure categories and CPT codes where provided. Applies to providers submitting claims to Premera Bluecross.
This policy has been revised.
Title changed from Site of Service Ambulatory Service Center Select Surgical Procedures in Adults to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.
Added Upper Gastrointestinal (UGI) Endoscopy in Adults (policy 2.01.533) to the list of procedures requiring site-of-service review.
Added cardiac surgery section to include implantable loop recorder surgery with CPT 33285 and HCPCS E0616.
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.
Added header clarifying that site-of-service review does not apply to Indian Health Services (IHS) facilities.
Site-of-Service Medical Necessity Criteria
Site of Service Medical Necessity Criteria
Site of service for elective surgical procedures will be determined by medical necessity. Ambulatory Surgical Center (ASC) is the preferred site when criteria below are met; hospital outpatient or inpatient settings may be appropriate when exceptions apply.
Hospital outpatient(s) may be considered when ANY of the following apply:
- No qualifying ASC within 30 miles that can provide the necessary care (no geographically accessible ASC with necessary equipment or availability).
- The ASC's specific guideline or policies prohibit use for this individual (e.g., related to individual’s health condition or weight).
- Patient is age 18 years or younger.
- The service is being performed in conjunction with an additional service that requires the use of a hospital outpatient department and both procedures are performed in the same operative session.
- Clinical risk factors exist that increase the risk of complications (see clinical risk node).
Clinical risk factors that may necessitate non-ASC setting (any of the following):
- Anesthesia risk: ASA classification III or higher; personal history of anesthesia complication; documentation of alcohol dependence or history of cocaine use; prolonged surgery (>3 hours).
- Cardiovascular risk: uncompensated chronic heart failure (NYHA III or IV); recent myocardial infarction (<3 months); poorly controlled or resistant hypertension (eg, requiring ≥3 drugs); recent cerebrovascular accident (<3 months); increased risk for cardiac ischemia (drug-eluting stent <1 year or angioplasty <90 days); symptomatic arrhythmia despite medication; significant valvular heart disease.
- Liver risk: advanced liver disease with MELD score greater than 8.
- Pulmonary risk: COPD with reduced FEV1 criteria; poorly controlled asthma (FEV1 <80% despite treatment); moderate to severe obstructive sleep apnea (AHI ≥15).
- Renal risk: end-stage renal disease on dialysis.
- Other: 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).
ASC medical necessity and procedure list expansions
The policy identifies select procedures considered medically necessary in an ASC when specified criteria are met and documents recent expansions to included procedure categories and codes.
Recent expansions and additions:
- Title and scope expanded to include diagnostic procedures (eg, Upper Gastrointestinal [UGI] Endoscopy in Adults).
- Policy history documents multiple effective-date and provider-notification timeline entries; provider notification lead time noted as 90 days for listed additions and changes.
Example and New CPT/HCPCS Codes; Operational Values
| 43235 | Esophagogastroduodenoscopy, flexible, transoral; diagnostic |
| 29848 | Endoscopy, wrist, surgical, with release of transverse carpal ligament |
| 27415 | Osteochondral allograft, knee, open / Osteochondral autograft(s), knee, open |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage |
| 19318 | Reduction mammaplasty |
Prior Authorization, Documentation, and Site-of-Service Review
Obtain prior authorization for site-of-service
Prior authorization is required for the site of service for the listed elective surgical and diagnostic procedures so Premera can review medical necessity and determine the most appropriate, safe, and cost‑effective setting (for example, Ambulatory Surgical Center vs hospital outpatient department).
Risk of denial if ASC criteria not met; allowable HOPD exceptions
An elective procedure performed in a hospital outpatient department will be considered medically necessary only when one of the policy exceptions applies—most commonly when there is no qualifying ASC within 30 miles, no ASC with the necessary equipment, ASC-specific guideline prohibits use for this individual, the patient is age 18 or younger, the procedure is combined with another that requires a hospital setting, or specified clinical risk factors are present.
- Distance/access exception: no qualifying ASC within 30 miles that can provide the necessary care
- ASC capability exception: no geographically accessible ASC with necessary equipment or available appointment
- Age/combined-procedure exception: patient ≤18 or procedure performed with another service requiring hospital setting
- Clinical-risk exception: See list of specified risk factors (ASA III+, cardiac, pulmonary, liver, renal, pregnancy, bleeding disorder, morbid obesity, anticipated transfusion)
Provide documentation to support site exceptions
When requesting a non‑ASC site, documentation must demonstrate lack of ASC access or the clinical risk factors that necessitate a hospital setting.
- Evidence of no accessible ASC within 30 miles or no ASC with required equipment/availability
- Clinical risk documentation (examples): ASA physical status III or higher, history of anesthesia complications, alcohol dependence or cocaine use, prolonged surgery (>3 hours)
- Cardiac: NYHA class III/IV heart failure, recent MI or CVA (<3 months), symptomatic arrhythmia, significant valvular disease, recent drug-eluting stent (<1 year) or angioplasty (<90 days)
- Pulmonary: COPD with documented FEV1 criteria, poorly controlled asthma (FEV1 <80%), moderate–severe OSA (AHI ≥15)
- Liver/renal/other: MELD >8, end‑stage renal disease on dialysis, pregnancy, bleeding disorder requiring replacement factor/blood products (DDAVP excluded), morbid obesity (BMI ≥50), anticipated transfusion need
Site‑of‑service review performed; providers notified ahead of changes
Premera will review site of service for select surgical or diagnostic procedures and consider ASC medically necessary when criteria are met; providers will be notified of policy changes and effective dates with the 90‑day provider notification timelines reflected in the policy history.
- Site‑of‑service determinations performed via prior authorization review for listed procedures
- Policy history shows additions/changes include 90‑day provider notification prior to effective dates for listed updates
IHS facilities are exempt from site‑of‑service review
The site‑of‑service review and ASC selection requirements do not apply to Indian Health Services (IHS) facilities.
Clinical Classifications and Place-of-Service Codes
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