CurrentRegence BlueCross BlueShieldPolicy 19
Surgical Site of Care - Hospital Outpatient
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This policy governs prior authorization for performing eligible surgical procedures in a hospital outpatient department rather than an ambulatory surgery center or physician office. It applies to outpatient hospital procedures on the policy's code list and evaluates individual health status, procedure risk, and other site-of-care considerations.
Policy Summary
PayerRegence BlueCross BlueShield
PolicySurgical Site of Care - Hospital Outpatient
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNovember 1, 2026
Last ReviewSep 1, 2026
Next Review DateJuly 1, 2027
Key ActionObtain prior authorization for listed surgical procedures performed in an outpatient hospital setting.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Hospital outpatientSite of care
ASCComparison setting
>3 hoursProlonged surgery threshold
>8%Uncontrolled diabetes threshold
>180/110Severe hypertension threshold
Hospital Outpatient Site-of-Care Coverage Criteria
Hospital Outpatient Site-of-Care Criteria
Hospital outpatient site of care may be appropriate when any of the following clinical, procedural, or individual circumstances apply:
ONE or more of the following
- Bleeding disorder requiring replacement factor or special infusion products to correct a coagulation defect.
- Complex anticoagulation management is anticipated.
- Transfusion is anticipated.
- Sickle cell disease.
Clinical documentation that cardiovascular risk is increased by any of the following
- Symptomatic cardiac arrhythmia despite medication.
- Coronary artery disease (CAD).
- Drug-eluting stents (DES) placed within one year, or bare-metal stents (BMS) or plain angioplasty within 90 days.
- History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) within the past three months.
- History of myocardial infarction (MI) within the past three months.
- Implantable cardioverter-defibrillator (ICD).
- Implanted pacemaker.
- Mechanical cardiovascular support, such as a left ventricular assist device (LVAD) or total artificial heart.
- Peripheral vascular disease (PVD).
- Ongoing evidence of myocardial ischemia.
- Severe hypertension (>180/110) or resistant hypertension not responsive to three antihypertensive medications.
- Uncompensated chronic heart failure (CHF), New York Heart Association (NYHA) class III or IV.
- Moderate or severe valvular heart disease and/or cardiomyopathy.
- Prolonged surgery (> 3 hours).> 3 hours
- Advanced liver disease, with a Model for End-Stage Liver Disease (MELD) score > 8.MELD score > 8
- Diabetes that is uncontrolled (HgbA1c > 8%) or associated with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia.HgbA1c > 8%
- End-stage renal disease (ESRD) or stage 4 or 5 chronic kidney disease.
- Incompletely treated skin or wound infection.
- Pregnancy.
Pulmonary risk is increased by any of the following
- Abnormal airway.
- Prior difficult intubation.
- Active respiratory infection.
- Chronic obstructive pulmonary disease (COPD), with FEV1 < 50%.FEV1 < 50%
- Medical conditions commonly connected with difficult airway, such as Pierre-Robin, Treacher-Collins, Goldenhar syndrome, or epidermolysis bullosa.
- Poorly controlled asthma, with FEV1 < 80% despite medical management.FEV1 < 80% despite medical management
- Moderate to severe obstructive sleep apnea: moderate means apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) > 15 and < 30; severe means AHI or RDI > 30 per hour.Moderate: AHI/RDI > 15 and < 30; severe: AHI/RDI > 30/hour
- Dependence on a ventilator or continuous supplemental oxygen.
- Personal history or family history of an anesthesia complication, such as malignant hyperthermia.
History of a gastrointestinal condition that increases aspiration risk
- Documented history of achalasia.
- Documented history of delayed gastric emptying disorder or gastroparesis.
History of a neurological diagnosis that increases risk
- Active multiple sclerosis.
- Myasthenia gravis.
- Severe motor disorder, such as severe Parkinson disease or other severe neurological dysfunction.
- A condition is present that will require the use of restraints.
- History of total joint infection.
- The individual is awaiting a major organ transplant.
- The procedure is a laparoscopic or vaginal hysterectomy and there is documented suspected malignant pathology, endometriosis, or an enlarged uterus (see Policy Guidelines).
- Risk of a procedure-specific complication.
- The individual has a documented disability that makes receiving care in an ASC setting inappropriate.
- The provider documents a requirement for overnight recovery based on a unique circumstance for the individual.
Medically Necessary Hospital Outpatient Site of Care
Use of a hospital outpatient department instead of an ASC for surgical services may be considered medically necessary when ALL of the following are met:
ALL of the following
- The procedure is of a level of complexity such that it may not be performed in a less intensive setting.
- The service being performed is medically necessary.
- The surgical site-of-care policy criteria are met.
Not Medically Necessary Hospital Outpatient Site of Care
Use of a hospital outpatient department instead of an ASC for surgical services is not medically necessary when any applicable policy condition indicates that hospital outpatient site of care is not warranted, including the following:
ANY of the following
- The procedure can be safely performed in a less intensive setting.
- The specific service requires prior authorization and does not meet the applicable policy criteria.
- The surgical site-of-care policy criteria are not met.
This policy does not address procedures performed in an ambulatory surgery center (ASC), physician office, or emergency facility for urgent services.
This policy addresses prior authorization for site of care only. The procedure may require prior authorization separately; see the applicable Medical Policy.
For coverage of a procedure in a hospital outpatient department, in addition to meeting the criteria in this medical policy, the type of service being performed must be considered medically necessary under prior authorization review requirements and the applicable medical policy, or the health plan must not require prior authorization for the service being performed.
The use of a hospital outpatient department for surgical services instead of an ambulatory surgery center or physician office is considered not medically necessary when the hospital outpatient site-of-care criteria are not met.
When hospital outpatient use is not medically necessary, the procedure should be performed in a lower-acuity setting, such as an ASC or physician office, when the procedure can be safely performed there.
Prior authorization requirements for the specific service remain applicable. The service must meet the applicable prior authorization and Medical Policy criteria, unless the health plan does not require prior authorization for that service.
Failure to meet the surgical site-of-care policy criteria supports denial of hospital outpatient site of care as not medically necessary.
Covered Procedure Codes and Clinical Thresholds
Surgical procedures subject to hospital outpatient site-of-care reviewCPT
| 10121 | Incision and removal of foreign body, subcutaneous tissues; complicated. |
| 10140 | Incision and drainage of hematoma, seroma or fluid collection. |
| 10160 | Puncture aspiration of abscess, hematoma, bulla, or cyst. |
| 10180 | Incision and drainage, complex, postoperative wound infection. |
| 11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. |
| 11406 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm. |
| 11420 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less. |
| 11422 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm. |
| 11423 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm. |
| 11424 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm. |
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CPT procedure codes listed in the hospital outpatient surgical site policyCPT
| 11443 | Description not fully legible in the source excerpt. |
| 11446 | Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair |
| 11450 | Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair |
| 11470 | Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair |
| 11601 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm |
| 11603 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm |
| 11606 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm |
| 11626 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm |
| 11750 | Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal |
| 11770 | Excision of pilonidal cyst or sinus; simple |
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Procedure codes listed in policyCPT
| 11601 | |
| 11603 | |
| 11606 | |
| 11626 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm |
| 11750 | Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal |
| 11770 | Excision of pilonidal cyst or sinus; simple |
| 11900 | Injection, intralesional; up to and including 7 lesions |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less |
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
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Procedure codes listed in this policy sectionCPT
| 11606 | |
| 11626 | |
| 11750 | Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal |
| 11770 | Excision of pilonidal cyst or sinus; simple |
| 11900 | Injection, intralesional; up to and including 7 lesions |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less |
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
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Procedure codesCPT
| 11750 | |
| 11770 | |
| 11900 | Injection, intralesional; up to and including 7 lesions |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less |
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
| 12035 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm |
| 12037 | Repair, intermediate, wounds of scalp, neck, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm |
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Procedure codes listed in the CODES sectionCPT
| 11770 | |
| 11900 | |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less |
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
| 12035 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm |
| 12037 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm |
| 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm |
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Listed CPT CodesCPT
| 11900 | |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less |
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
| 12035 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm |
| 12037 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm |
| 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm |
| 13160 | Secondary closure of surgical wound or dehiscence, extensive or complicated |
CODESCPT
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
| 12020 | Treatment of superficial wound dehiscence; simple closure |
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm |
| 12035 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm |
| 12037 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm |
| 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm |
| 13160 | Secondary closure of surgical wound or dehiscence, extensive or complicated, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
CODESCPT
| 14020 | Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less |
| 14040 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less |
| 14060 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less |
| 15120 | Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) |
| 15240 | Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less |
CODESCPT
| 17000 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion |
| 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions |
| 17311 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks |
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation |
CodesCPT
| 17000 | |
| 17110 | Vascular proliferative lesions; up to 14 lesions |
| 17311 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks |
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks |
| 19020 | Mastotomy with exploration or drainage of abscess, deep |
| 19101 | Biopsy of breast; open, incisional |
| 19120 | Excision 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 |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological |
Procedure Codes ListedCPT
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks |
| 19020 | Mastotomy with exploration or drainage of abscess, deep |
| 19101 | Biopsy of breast; open, incisional |
| 19120 | Excision 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 |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 20225 | Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) |
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate |
CODESCPT
| 17313 | trunk, arms, or legs; first stage, up to 5 tissue blocks |
| 19020 | Mastotomy with exploration or drainage of abscess, deep |
| 19101 | Biopsy of breast; open, incisional |
| 19120 | Excision 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 |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 20225 | Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) |
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) |
| 20680 | Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) |
Hospital outpatient procedure codesCPT
| 19020 | |
| 19101 | Biopsy of breast; open, incisional |
| 19120 | Excision 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 |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 20225 | Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) |
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) |
| 20680 | Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) |
| 20694 | Removal, under anesthesia, of external fixation system |
| 20912 | Cartilage graft; nasal septum |
Procedure codes listed in the hospital outpatient surgical site-of-care code tableCPT
| 19020 | |
| 19101 | Biopsy of breast; open, incisional |
| 19120 | Excision of breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 20225 | Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) |
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) |
| 20680 | Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) |
| 20694 | Removal, under anesthesia, of external fixation system |
| 20912 | Cartilage graft; nasal septum |
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Procedure CodesCPT
| 19020 | |
| 19101 | |
| 19120 | female, 1 or more lesions |
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 20225 | Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) |
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) |
| 20680 | Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) |
| 20694 | Removal, under anesthesia, of external fixation system |
| 20912 | Cartilage graft; nasal septum |
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Prolonged surgery
CircumstanceProlonged surgery
ThresholdMore than 3 hours
Site-of-care relevanceA documented prolonged surgery may support hospital outpatient care rather than ASC or physician-office care.
Advanced liver disease
CircumstanceAdvanced liver disease
ThresholdMELD score greater than 8
Site-of-care relevanceA documented MELD score above 8 may support hospital outpatient care.
Uncontrolled diabetes
CircumstanceUncontrolled diabetes
ThresholdHgbA1c greater than 8%
Additional qualifying conditionsRecurrent diabetic ketoacidosis or severe hypoglycemia also qualify under the diabetes circumstance.
Severe hypertension
Risk categorySevere hypertension
Blood pressure thresholdGreater than 180/110
Additional hypertension circumstanceResistant hypertension not responsive to three antihypertensive medications is also listed.
Poorly controlled asthma
Risk categoryPoorly controlled asthma
Pulmonary-function thresholdFEV1 less than 80% despite medical management
Site-of-care relevanceThis is listed as an increased pulmonary or airway risk factor.
Chronic obstructive pulmonary disease
Risk categoryChronic obstructive pulmonary disease (COPD)
Pulmonary-function thresholdFEV1 less than 50%
Site-of-care relevanceThis is listed as an increased pulmonary risk factor.
Moderate obstructive sleep apnea
Risk categoryModerate obstructive sleep apnea
Diagnostic thresholdAHI or RDI greater than 15 and less than 30
MeasurementAHI means apnea-hypopnea index; RDI means respiratory disturbance index.
Severe obstructive sleep apnea
Risk categorySevere obstructive sleep apnea
Diagnostic thresholdAHI or RDI greater than 30 per hour
Site-of-care relevanceModerate-to-severe obstructive sleep apnea is listed as an increased pulmonary or airway risk factor.
Morbid obesity
ASA exampleMorbid obesity
BMI thresholdBMI greater than or equal to 40
Classification contextMorbid obesity is included among examples of substantive functional limitations or moderate-to-severe disease.
Enlarged uterus
Clinical examinationUterine size greater than 14 weeks
Imaging lengthGreater than 10 cm
Estimated weightGreater than 100 g
Malignant lesion excision diameter
Malignant lesion diameter0.6 to 1.0 cm
Malignant lesion diameter2.1 to 3.0 cm
Malignant lesion diameterOver 4.0 cm
Intralesional injection lesion count
ProcedureIntralesional injection
Lesion countUp to and including 7 lesions
CPT code11900
Simple superficial wound repair
Repair typeSimple repair of superficial wounds
Anatomic sitesScalp, neck, axillae, external genitalia, trunk and/or extremities, including hands and feet
Length2.5 cm or less
Malignant lesion excision diameter
Lesion typeMalignant lesion
Excision diameterOver 4.0 cm
Listed anatomic sitesTrunk, arms, legs, scalp, neck, hands, feet, or genitalia
Simple superficial wound repair
Repair typeSimple repair of superficial wounds
Length2.5 cm or less
Included sitesScalp, neck, axillae, external genitalia, trunk and/or extremities, including hands and feet
Simple superficial wound repair
Repair typeSimple repair of superficial wounds
Length range2.6 cm to 7.5 cm
Included sitesScalp, neck, axillae, external genitalia, trunk and/or extremities, including hands and feet
Mohs first-stage tissue blocks
ProcedureMohs micrographic technique, first stage
Tissue blocksUp to 5 tissue blocks
Technique includesRemoval of gross tumor, tissue mapping, microscopic examination, and histopathologic preparation
Vascular proliferative lesions
Lesion typeVascular proliferative lesions
Lesion countUp to 14 lesions
Procedure contextThe listed lesion-destruction service includes treatment of up to 14 lesions.
Authorization and Documentation Requirements
Prior Authorization
Hospital Outpatient Site-of-Care Authorization
Prior authorization for site of care applies to surgical procedures on the policy’s Codes list when performed in a hospital outpatient setting. This policy does not address procedures performed in an ASC, physician office, or emergency facility for urgent services.
- Site-of-care medical necessity reviews apply only to listed surgical procedures performed in an outpatient hospital setting.
Prior Authorization
Obtain Authorization for Outpatient Hospital Procedures
Obtain authorization for listed surgical procedures performed in a hospital outpatient department. The site-of-care review determines whether hospital outpatient use is medically necessary under the policy criteria.
- Submit the request for site-of-care review when the procedure is performed in an outpatient hospital setting.
- The procedure may require separate prior authorization under the applicable Medical Policy.
Documentation Required
Required Clinical Records
Submit the clinical records needed to determine whether the site-of-care criteria are met. Missing information may affect the review and authorization decision.
- History and physical or chart notes.
- American Society of Anesthesiologists (ASA) score, as applicable.
- Clinical documentation supporting the specific policy criteria and the requested site of care.
- When faxing a pre-authorization request, use the Surgical Site of Care Additional Information form when possible.
Documentation Required
Additional Procedure Documentation
For services requiring prior authorization in addition to site-of-care review, submit the clinical documentation required by the applicable medical policy for the procedure.
- Procedure-specific authorization requirements apply separately from site-of-care authorization.
- Include all applicable medical policy clinical documentation with the request.
Denial Risk
Site-of-Care Criteria Not Met
Use of a hospital outpatient department may be determined not medically necessary when the site-of-care criteria are not satisfied.
- This includes cases in which the procedure can be safely performed in a less intensive setting.
Denial Risk
Underlying Procedure Must Be Medically Necessary
The underlying surgical procedure must independently be medically necessary under applicable prior authorization requirements and the applicable Medical Policy, unless the health plan does not require prior authorization for that service.
- Site-of-care authorization does not replace authorization or medical-necessity requirements for the procedure itself.
Denial Risk
Lower-Acuity Site May Be Appropriate
Hospital outpatient use instead of an ambulatory surgical center is not medically necessary when the procedure can be safely performed in a less intensive setting and no policy criterion supports the hospital setting.
- Confirm that the individual’s clinical circumstances require the hospital outpatient level of care.
Denial Risk
Prior Authorization Criteria Must Be Met
Hospital outpatient use is not medically necessary when a specific service requires prior authorization and the applicable authorization or medical policy criteria are not met.
- Meet both the procedure-specific authorization requirements and the site-of-care policy criteria, when applicable.
Denial Risk
Failure to Meet Site-of-Care Criteria
Failure to meet the surgical site-of-care policy criteria may result in a finding that hospital outpatient use is not medically necessary.
- Document the clinical circumstances that qualify the individual for the requested hospital outpatient site of care.
Policy Background
An ambulatory surgery center (ASC) is a same-day surgical facility outside the hospital and does not have inpatient beds. Determining whether hospital outpatient care is appropriate may depend on the individual’s health status, facility and geographic availability, specialty requirements, physician privileges, ASA physical status, and significant comorbidities, including serious cardiorespiratory disease, moderate-to-severe obstructive sleep apnea, pregnancy, or poorly controlled asthma.
Key Definitions
Ambulatory surgery center (ASC)
Facility typeHealth care facility offering same-day surgery outside the hospital setting
Inpatient bedsDoes not have inpatient beds
SponsorshipMay or may not be sponsored by a hospital
ASA physical status classification
PurposeGrades preoperative systemic health
Classification rangeASA I through ASA VI
Emergency designationThe addition of E denotes emergency surgery when delaying treatment would significantly increase the threat to life or body part.
Enlarged uterus
Clinical sizeGreater than 14 weeks on clinical examination
Imaging lengthGreater than 10 cm
Estimated weightGreater than 100 g
ASA Physical Status Classification System
SystemAmerican Society of Anesthesiologists Physical Status Classification System
ContentDefinitions and ASA-approved examples
UseUsed with other factors to aid in predicting perioperative risks.
Surgical site of care
DefinitionThe location where the surgical service is performed
Hospital setting evaluatedHospital outpatient department
Comparison settingAmbulatory surgical center (ASC)
Ambulatory surgical center (ASC)
Facility settingLess intensive than a hospital outpatient department
Policy rolePrincipal comparison site for hospital outpatient surgical services
Medical necessity contextHospital outpatient use may be considered when the procedure cannot be performed in a less intensive setting and the policy criteria are met.
Policy Summary
PayerRegence BlueCross BlueShield
PolicySurgical Site of Care - Hospital Outpatient
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNovember 1, 2026
Last ReviewSep 1, 2026
Next Review DateJuly 1, 2027
Key ActionObtain prior authorization for listed surgical procedures performed in an outpatient hospital setting.
SourceLink
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