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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyPremera Site of Service Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentPremera Blue Cross of WashingtonPolicy N/A

    Site of Service for Selected Elective Surgical and Diagnostic Procedures

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    This policy governs medical necessity review of the location where certain listed elective procedures are performed, including ambulatory surgical centers, outpatient hospitals, and inpatient hospitals. The procedure itself is not subject to medical necessity review under this policy; providers must obtain prior authorization for site of service when required and document why a higher-cost setting is appropriate.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicySite of Service for Selected Elective Surgical and Diagnostic Procedures
    Policy CodePolicy N/A
    Change TypeNew policy
    Effective DateJanuary 1, 2027
    Next Review DateN/A
    Key ActionObtain prior authorization for the site of service when required and document why a hospital outpatient setting is medically necessary.
    SourceLink
    POLICY UPDATE CHANGES

    A new site-of-service policy was approved September 8, 2026 and applies to dates of service on or after January 1, 2027.

    The related medical policy title was updated from Synthetic Cartilage Implants for Joint Pain to Cartilage Implants for Joint Pain.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5Site-of-service settings addressed
    9Procedure categories listed
    30 milesASC exception distance
    18 or youngerAge exception
    BMI ≥ 50Morbid-obesity threshold
    3 hoursProlonged-surgery threshold

    Site-of-Service Medical Necessity

    Medically Necessary Site of Service

    The medically necessary site of service for certain elective procedures is the most appropriate, safe, and cost-effective location. The site of service is the location where the procedure is performed.

    ONE of the following sites of service

    • Ambulatory surgical center
    • Off-campus outpatient hospital or medical center
    • On-campus outpatient hospital or medical center

    Hospital Outpatient Medical Necessity Exceptions

    An elective procedure performed in a hospital outpatient department may be considered medically necessary when ALL of the following apply:

    ALL of the following

    • The procedure is an elective procedure being performed in a hospital outpatient department.

    • ONE of the following exceptions applies

      • There is no qualifying ambulatory surgical center within 30 miles that can provide the necessary care because there is no geographically accessible ambulatory surgical center with the necessary equipment to perform the procedure.
      • There is no qualifying ambulatory surgical center within 30 miles that can provide the necessary care because there is no geographically accessible ambulatory surgical center at which the individual's physician has privileges.
      • An ambulatory surgical center's specific guideline prohibits use of the ambulatory surgical center because of the individual's health condition or weight.
      • The individual is aged 18 or younger.
      • The service is performed in conjunction with an additional service that requires use of a hospital outpatient department, and both procedures are performed in the same operative session.

      • The individual has a clinical condition that increases the risk for complications, including ONE or more of the following

    Not Medically Necessary Site of Service

    The following sites of service are not medically necessary for certain elective procedures when the applicable site-of-service criteria above are not met.

    ONE of the following sites of service

    • Off-campus outpatient hospital or medical center when the applicable site-of-service criteria are not met.
    • On-campus outpatient hospital or medical center when the applicable site-of-service criteria are not met.
    • Inpatient hospital or medical center for the elective procedure.

    The Site of Service Medical Necessity criteria within this policy do not apply to Indian Health Services (IHS) facilities.

    An inpatient hospital or medical center is not medically necessary for the listed elective procedure.

    An off-campus or on-campus outpatient hospital or medical center is not medically necessary for the listed elective procedure when the applicable site-of-service criteria are not met.

    Covered Procedure Categories and Exception Thresholds

    Breast/Gynecology SurgeryCPTCovered
    19120Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions.
    19125Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion.
    58555Hysteroscopy, diagnostic (separate procedure).
    58558Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C.
    58560Hysteroscopy, surgical; with division or resection of intrauterine septum (any method).
    58561Hysteroscopy, surgical; with removal of leiomyomata.
    58562Hysteroscopy, surgical; with removal of impacted foreign body.
    58563Hysteroscopy, surgical; with endometrial ablation.
    Ear, Nose, Throat (ENT) SurgeryCPTCovered
    30140Submucous resection inferior turbinate, partial or complete, any method.
    30520Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft.
    42821Tonsillectomy & adenoidectomy; age 12 or over.
    42826Tonsillectomy, primary or secondary; age 12 or over.
    42870Excision or destruction lingual tonsil, any method (separate procedure).
    Gastrointestinal ProceduresCPTCovered
    45330Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).
    45331Sigmoidoscopy, flexible; with biopsy, single or multiple.
    45332Sigmoidoscopy, flexible; with removal of foreign body(s).
    45333Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
    45334Sigmoidoscopy, flexible; with control of bleeding, any method.
    45335Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance.
    45381Colonoscopy, flexible; with directed submucosal injection(s), any substance.
    45382Colonoscopy, flexible; with control of bleeding, any method.
    45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
    45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
    1–10 of 12
    1/2
    Gastrointestinal ProceduresHCPCSCovered
    G0104Colorectal cancer screening; flexible sigmoidoscopy.
    G0105Colorectal cancer screening; colonoscopy on individual at high risk.
    G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
    General and Plastic Surgery; Orthopedic/Podiatry SurgeryCPTCovered
    14020Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less.
    14040Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.
    14060Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less.
    49505Repair initial inguinal hernia, age 5 years or older; reducible.
    49650Laparoscopy, surgical; repair initial inguinal hernia.
    49651Laparoscopy, surgical; repair recurrent inguinal hernia.
    20612Aspiration and/or injection of ganglion cyst(s) any location.
    23430Tenodesis of long tendon of biceps.
    24071Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater.
    24341Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff).
    1–10 of 20
    1/2
    Orthopedic/Podiatry SurgeryCPTCovered
    28122Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or bossing); tarsal or metatarsal.
    28289Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy).
    28291Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant.
    28296Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method.
    28297Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method.
    28298Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method.
    28299Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method.
    29893Endoscopic plantar fasciotomy.
    64718Neuroplasty and/or transposition; ulnar nerve at elbow.
    Urology ProceduresCPTCovered
    50590Lithotripsy, extracorporeal shock wave.
    51715Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck.
    52000Cystourethroscopy (separate procedure).
    52310Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple.
    52332Cystourethroscopy, with insertion of indwelling ureteral stent.
    52356Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent.
    55250Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s).
    55700Biopsy, prostate; needle or punch, single or multiple, any approach.
    ASC geographic access
    Geographic exceptionNo qualifying ambulatory surgical center is available within 30 miles.
    Equipment or privilegesThe accessible ASC lacks the necessary equipment, or no accessible ASC is available where the physician has privileges.
    Health or weight restrictionAn ASC’s specific guideline prohibits its use because of the individual’s health condition or weight.
    Prolonged surgery
    Risk categoryAnesthesia risk associated with prolonged surgery.

    Authorization and Documentation Requirements

    Prior Authorization

    Obtain site-of-service authorization

    Prior authorization may be required for the site of service for procedures listed in this policy. The requested site may be reviewed even though the procedure itself is not subject to medical necessity review under this policy.

    Documentation Required

    Support the requested site of service

    Document the requested site of service and the facts supporting medical necessity for hospital outpatient care. Include applicable details such as ASC availability and distance, equipment or physician-privilege limitations, ASC restrictions related to the individual’s health condition or weight, age, same-session services, or other qualifying circumstances.

    Documentation Required

    Policy Rationale

    The same surgical or diagnostic procedure may be performed safely in different settings, but the cost can vary by setting. This policy promotes use of the safest, most appropriate, and cost-effective site of service, generally favoring an ambulatory surgical center for listed elective procedures while allowing hospital outpatient care when access, age, same-session services, or patient-risk circumstances justify it.

    Key Terms and Classifications

    Site of service
    Off-campus outpatient hospital or medical centerA portion of an off-campus hospital provider-based department providing diagnostic, therapeutic, and rehabilitation services to people who do not require hospitalization or institutionalization.
    On-campus outpatient hospital or medical centerA portion of a hospital’s main campus providing diagnostic, therapeutic, and rehabilitation services to people who do not require hospitalization or institutionalization.
    Ambulatory surgical centerA freestanding facility where surgical and diagnostic services are provided on an ambulatory basis.
    Inpatient hospital or medical centerA facility primarily providing diagnostic, therapeutic, and rehabilitation services to admitted patients.
    ASA physical status classification
    ASA III
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicySite of Service for Selected Elective Surgical and Diagnostic Procedures
    Policy CodePolicy N/A
    Change TypeNew policy
    Effective DateJanuary 1, 2027
    Next Review DateN/A
    Key ActionObtain prior authorization for the site of service when required and document why a hospital outpatient setting is medically necessary.
    SourceLink
    On This Page
    Site-of-Service Medical NecessityCovered Procedure Categories and Exception ThresholdsAuthorization and Documentation RequirementsPolicy RationaleKey Terms and Classifications
    • Anesthesia risk: ASA classification III or higher.
    • Anesthesia risk: personal history of a complication of anesthesia.
    • Anesthesia risk: documented alcohol dependence or history of cocaine use.
    • Anesthesia risk: prolonged surgery lasting greater than 3 hours.
    • Cardiovascular risk: uncompensated chronic heart failure, NYHA class III or IV.
    • Cardiovascular risk: recent myocardial infarction, less than 3 months ago.
    • Cardiovascular risk: poorly controlled, resistant hypertension.

      Resistant hypertension means use of 3 or more drugs to control blood pressure.

    • Cardiovascular risk: recent cerebrovascular accident, less than 3 months ago.
    • Cardiovascular risk: increased risk for cardiac ischemia due to a drug-eluting stent placed less than 1 year ago or angioplasty performed less than 90 days ago.
    • Cardiovascular risk: symptomatic cardiac arrhythmia despite medication.
    • Cardiovascular risk: significant valvular heart disease.
    • Liver risk: advanced liver disease.MELD score > 8
    • Pulmonary risk: chronic obstructive pulmonary disease.FEV1 < 50%
    • Pulmonary risk: poorly controlled asthma despite treatment.FEV1 < 80%
    • Pulmonary risk: moderate to severe obstructive sleep apnea.

      Moderate OSA: AHI ≥ 15 and ≤ 30. Severe OSA: AHI ≥ 30.

    • Renal risk: end-stage renal disease requiring dialysis.
    • Other: morbid obesity.BMI ≥ 50
    • Other: pregnancy.
    • Other: bleeding disorder requiring replacement factor, blood products, or a special infusion product.

      DDAVP (desmopressin) does not meet this criterion.

    Duration thresholdSurgery greater than 3 hours.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    Advanced liver disease
    Risk categoryLiver risk associated with advanced liver disease.
    Severity measureMELD score greater than 8.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    COPD
    Risk categoryPulmonary risk associated with chronic obstructive pulmonary disease.
    Pulmonary-function thresholdFEV1 less than 50%.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    Poorly controlled asthma
    Risk categoryPulmonary risk associated with poorly controlled asthma.
    Pulmonary-function thresholdFEV1 less than 80% despite treatment.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    Obstructive sleep apnea
    Risk categoryPulmonary risk associated with moderate to severe obstructive sleep apnea.
    Moderate OSA thresholdAHI greater than or equal to 15 and less than or equal to 30.
    Severe OSA thresholdAHI greater than or equal to 30.
    Morbid obesity
    Risk categoryOther clinical risk associated with morbid obesity.
    Body-mass thresholdBMI greater than or equal to 50.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    Recent myocardial infarction or cerebrovascular accident
    Cardiovascular eventRecent myocardial infarction within 3 months.
    Cerebrovascular eventRecent cerebrovascular accident within 3 months.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.
    Cardiac ischemia risk
    Risk categoryIncreased risk for cardiac ischemia.
    Drug-eluting stentPlaced less than 1 year before the procedure.
    AngioplastyPerformed less than 90 days before the procedure.
    Poorly controlled resistant hypertension
    Risk categoryCardiovascular risk associated with poorly controlled, resistant hypertension.
    Medication requirementThree or more drugs are required to control blood pressure.
    Hospital outpatient exceptionMay support hospital outpatient site of service when the individual has a clinical condition that increases complication risk.

    Document the clinical-risk exception

    When relying on a clinical-risk exception, document the relevant diagnosis or condition and the applicable severity measure or threshold supporting increased complication risk.

    • ASA classification III or higher or a personal history of anesthesia complication
    • Prolonged surgery greater than 3 hours
    • MI or cerebrovascular accident less than 3 months ago
    • MELD score greater than 8, COPD with FEV1 less than 50%, or poorly controlled asthma with FEV1 less than 80% despite treatment
    • Moderate OSA with AHI greater than or equal to 15 and less than or equal to 30, or severe OSA with AHI greater than or equal to 30
    • Morbid obesity with BMI greater than or equal to 50
    • Drug-eluting stent placed less than 1 year ago or angioplasty less than 90 days ago
    • Resistant hypertension requiring 3 or more drugs to control blood pressure
    Denial Risk

    Avoid inpatient site-of-service denials

    An inpatient hospital or medical center is considered not medically necessary for a listed elective procedure under this policy.

    Denial Risk

    Meet hospital outpatient criteria

    An off-campus or on-campus outpatient hospital or medical center is considered not medically necessary when the site-of-service criteria supporting hospital outpatient care are not met.

    Denial Risk

    Document why an ASC cannot be used

    A hospital outpatient site may be denied when a qualifying ambulatory surgical center is available and none of the documented exceptions applies. Document the applicable exception, such as no qualifying ASC within 30 miles, age 18 or younger, a same-session service requiring a hospital outpatient department, or a qualifying increased-risk clinical condition.

    A patient with severe systemic disease and substantive functional limitations.
    ASA IVA patient with severe systemic disease that is a constant threat to life.
    Policy applicationASA classification III or higher is used as an anesthesia-risk exception.
    NYHA classification
    NYHA Class IIIMarked limitation in activity due to symptoms, even during less-than-ordinary activity; comfortable only at rest.
    NYHA Class IVSevere limitation; symptoms occur even while at rest, and patients are mostly bedbound.
    Policy applicationUncompensated chronic heart failure of NYHA Class III or IV is a cardiovascular-risk exception.
    Ambulatory surgical center
    Facility typeA freestanding facility other than a physician’s office.
    ServicesSurgical and diagnostic services are provided on an ambulatory basis.
    Professional place-of-service codeCode 24 identifies an ambulatory surgical center.