Outpatient Surgical Site of Service — Appendix (knee, shoulder, small joint procedures)
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Defines medical necessity review of hospital outpatient site of service (Place of Service 22) for knee, shoulder, and small joint outpatient procedures for Providence Health Plan commercial fully insured groups; affects providers requesting prior authorization for these procedures and their planned site of service.
Effective 5/11/2026 the Plan will review medical necessity of a hospital outpatient site of service (place of service 22) for selected knee, shoulder, and small joint procedures.
If medical policy criteria are not met for the outpatient site of service, the service must be performed at an ambulatory surgery center (ASC) for coverage.
Providers without geographically accessible ASC privileges must have a signed attestation on file or indicate unavailability on the prior authorization request to avoid delays.
Coverage and Applicability
Coverage contingent on procedure criteria and site-of-service review
Covered when procedure-level medical necessity criteria are met and the outpatient site-of-service review supports hospital outpatient setting OR when ASC is unavailable with attestation:
Primary requirements
- Acceptable documentation when ASC is not available: Provider has either: a signed attestation on file with The Plan confirming no geographically accessible ASC or privileges at an accessible ASC; OR indicates on the prior authorization request that no ASC is available (prospective attestation encouraged).
Attestation may be submitted prospectively to facilitate future reviews
This Appendix applies to selected outpatient orthopedic procedures for Providence Health Plan commercial fully insured groups and does not apply to Providence Medicare and Providence OHP members. Changes described in this Appendix do not supersede member-specific benefit determinations of coverage. Coverage for the listed procedures is contingent on meeting the procedure-level medical necessity criteria and the Plan’s site-of-service review for the planned outpatient setting (Place of Service 22).
If medical policy criteria are not met for the hospital outpatient site of service (Place of Service 22), performing the service in that setting is not covered; to be covered the service must be performed at an ambulatory surgery center (ASC). Providers should note that failure to meet site-of-service criteria may result in denial or non-coverage when the procedure is performed in a hospital outpatient setting.
Prior Authorization Codes and Place of Service
| 27422 | Reconstruction of dislocating patella; with extensor realignment and/or muscle. |
| 27427 | Ligamentous reconstruction (augmentation), knee; extra-articular. |
| 27428 | Ligamentous reconstruction (augmentation), knee; intra-articular (open). |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage. |
| 29873 | Arthroscopy, knee, surgical; with lateral release. |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body. |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (separate procedure). |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments. |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty) or multiple drilling or microfracture. |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial and lateral) including debridement/shaving of articular cartilage (chondroplasty). |
Prior Authorization, Attestation, and Denial Risk
Prior authorization and site-of-service review required
Prior authorization is required for the listed knee, shoulder, and small joint procedures; the Plan will also review the medical necessity of a hospital outpatient site of service (Place of Service 22) for planned procedures. There are no changes to existing PA requirements for the procedures themselves, but medical necessity review of the outpatient site will be added effective 5/11/2026.
- PA remains required for the procedure-level clinical criteria and listed CPT codes.
- The Plan will review medical necessity for hospital outpatient site of service (POS 22) in addition to procedure PA.
Make POS 22 clear on the PA and use portal/attestation to avoid delays
Indicate on the PA request if the procedure will be performed in a hospital outpatient setting (Place of Service 22); providers are encouraged to use the Care Advance Provider Portal to complete the medical necessity questionnaires to streamline review and may submit a prospective ASC attestation to facilitate future reviews.
- Make clear on the PA whether the planned POS is 22.
- Use the Care Advance Provider Portal for medical necessity questionnaires; this may allow automatic authorization when criteria are met.
- Providers anticipating future site-of-service requests should consider filing a prospective attestation now.
Site-of-service indication and ASC attestation required on PA
PA requests must clearly indicate if the procedure will be performed in a hospital outpatient setting (Place of Service 22). If no geographically accessible ASC is available or the provider lacks privileges at an accessible ASC, the provider must either have a signed attestation on file with the Plan or indicate unavailability on the prior authorization request to prevent delays.
- Submit a signed ASC attestation to the Plan (can be prospective), OR
- If no attestation is on file, indicate on the PA request that no ASC is available.
Denial risk if site-of-service criteria for POS 22 are not met
If medical policy criteria are not met for the hospital outpatient site of service (POS 22), the service must be performed at an ambulatory surgery center (ASC) for coverage; failure to meet site-of-service criteria may result in denial or non‑coverage when performed in the hospital outpatient setting.
- Perform the service at an ASC to maintain coverage if POS 22 criteria are not met.
Background and Scope
This Appendix is an administrative policy governing site-of-service review for selected knee, shoulder, and small joint outpatient procedures and is not intended as clinical treatment guidance. It establishes that, effective 5/11/2026, the Plan will review medical necessity of a hospital outpatient site of service (Place of Service 22) in addition to existing procedure-level prior authorization and medical necessity requirements.
Key Definitions
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