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Site of Service Ambulatory Service Center (ASC) Select
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Defines medical necessity criteria and prior authorization expectations for the site of service (ASC, hospital outpatient, inpatient) for certain elective adult surgical procedures and lists included procedure categories and CPT codes; intended for providers and affects Premera-covered members and their providers.
No material clinical or coverage changes in this revision.
Site-of-Service Coverage Criteria
Site-of-service medical necessity criteria
Covered when ALL of the following are met:
Hospital outpatient may be considered medically necessary if ANY of the following apply:
- There is no geographically accessible qualifying ASC within 30 miles that has the necessary equipment to perform the procedure.
- There is no geographically accessible ASC at which the individual's physician has privileges.
- The individual is age 18 years or younger.
- The service is being performed in conjunction with an additional service that requires a hospital outpatient department and both procedures are performed in the same operative session.
Hospital (outpatient or inpatient) site may be necessary for patients with increased clinical risk, including ANY of the following examples:
- 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 expected (greater than 3 hours).
- Cardiovascular risk: uncompensated chronic heart failure (NYHA class III or IV).
- Cardiovascular risk: recent myocardial infarction (less than 3 months).
- Cardiovascular risk: poorly controlled, resistant hypertension (requiring 3 or more drugs to control blood pressure).
- Cardiovascular risk: recent cerebrovascular accident (less than 3 months).
- Cardiovascular risk: increased risk for cardiac ischemia (drug eluting stent placed less than 1 year or angioplasty less than 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 less than 50%.
- Pulmonary risk: poorly controlled asthma (FEV1 less than 80% despite treatment).
- Renal risk: end stage renal disease on dialysis.
- Other: morbid obesity (BMI greater than or equal to 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).
Site-of-Service ASC Select Procedures - high-level stance
Policy scope and applicability — high-level statement:
Procedure and Coding References
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral) including debridement/shaving of articular cartilage |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral) including debridement/shaving of articular cartilage |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural |
Provider Requirements and Prior Authorization
Site‑of‑service prior authorization required
Prior authorization is required for the site of service for the surgical procedures listed to encourage use of the most safe, appropriate, and cost‑effective site (ASC preferred).
- Prior authorization applies to listed elective ambulatory surgical procedures.
- Purpose: ensure the most appropriate, safe, and cost‑effective location, with ASC as the preferred site.
When hospital outpatient site is permitted
An elective surgical procedure performed in a hospital outpatient department may be considered medically necessary when no qualifying ASC is accessible within 30 miles, no geographically accessible ASC has the necessary equipment or the physician lacks privileges at an ASC, or when the patient meets specified clinical risk or age/adjunct‑service criteria.
- No qualifying ASC within 30 miles that can provide the necessary care; or no geographically accessible ASC with required equipment; or no geographically accessible ASC where the physician has privileges.
- Patient is age 18 or younger, or the service is performed with an additional service that requires a hospital outpatient department in the same operative session.
- Patient has specified clinical risk factors (examples include ASA III+, recent MI <3 months, uncompensated CHF NYHA III/IV, COPD with FEV1 <50%, prolonged surgery >3 hours, BMI ≥50, advanced liver disease MELD >8, bleeding disorder, ESRD on dialysis).
ASC site‑of‑service medical necessity statement
Site of Service in an Ambulatory Surgical Center (ASC) will be considered medically necessary for select surgical procedures when the policy’s site‑of‑service criteria are met.
- ASC is the preferred medically necessary site when criteria in the policy (geographic access, equipment/privilege availability, and absence of listed clinical risk factors) are satisfied.
- When criteria are not met, hospital outpatient or inpatient sites may be considered per the policy rules.
Key Clinical and Billing Definitions
Policy Revision History
New Utilization Management Guideline approved July 8, 2025; effective for dates of service on or after November 7, 2025 following 90-day provider notification; ASC considered medically necessary when criteria are met.
Interim review approved October 14, 2025; effective for dates of service on or after February 6, 2026 following 90-day provider notification; added shoulder arthroscopy and CPT codes 23700, 29805-29807, 29819-29828 to ASC select procedures.
Referenced treatment of articular cartilage lesions with policy 7.01.607 added to history.
Interim review approved November 11, 2025; minor update to ASA Physical Status Classification table (added adult examples) and multiple policy changes effective March 4, 2026 including title change and addition of UGI Endoscopy (2.01.533) to procedures requiring site-of-service review.
Interim review approved December 23, 2025; policy changes effective April 8, 2026 included addition of a Cardiac Surgery section and CPT code 33285 for implantable loop recorder insertion.
Minor clarification to policy history and notation of implantable loop recorders within the policy and related policies.
Interim review approved February 10, 2026; changes effective June 5, 2026 added Hand Surgery section and CPT codes 29848 and 64721 and related policy 7.01.595 for carpal tunnel release techniques.
Minor update added a header clarifying that site-of-service review does not apply to Medicare Advantage.
Policy effective date updated from July 1, 2026 to September 1, 2026 for inclusion of 2.01.533 Upper Gastrointestinal (UGI) Endoscopy in Adults to the list of procedures requiring ASC site-of-service review.
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