CurrentRegencePolicy 20

Surgical Site of Care - Colonoscopy and Sigmoidoscopy

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This policy governs prior authorization for performing colonoscopy or sigmoidoscopy in a hospital outpatient department instead of an ambulatory surgery center or physician office. It applies to outpatient hospital site-of-care requests when specified medical-necessity criteria or qualifying individual risk factors are documented.

Policy Summary

PayerRegence

PolicySurgical Site of Care - Colonoscopy and Sigmoidoscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewSep 1, 2026

Next Review DateAugust 1, 2027

Key ActionSubmit history and physical or chart notes, the ASA score when applicable, and documentation supporting the specific site-of-care criterion.

SourceLink

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CurrentRegencePolicy 20

Surgical Site of Care - Colonoscopy and Sigmoidoscopy

Customize your policy alerts

Sign up for regence Policy 20 alerts

Get alerted when Policy 20 changes without checking for updates manually.

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Policy Summary

PayerRegence

PolicySurgical Site of Care - Colonoscopy and Sigmoidoscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewSep 1, 2026

Next Review DateAugust 1, 2027

Key ActionSubmit history and physical or chart notes, the ASA score when applicable, and documentation supporting the specific site-of-care criterion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Listed procedure codes

25 milesASC access distance

≤17 yearsAge criterion

III+ASA threshold

>40BMI criterion

Hospital Outpatient Site-of-Care Criteria

Medically Necessary Hospital Outpatient Site of Care

Covered as medically necessary when one or more of the following criteria is met.

Hospital outpatient site-of-care criteria

Inaccessible or unsuitable ASC: There is no qualifying in-network ASC within 25 miles of the individual's residence that can provide the necessary care because the ASC lacks necessary equipment; no available ASC has the individual's physician's privileges and the individual requires diagnostic colonoscopy or sigmoidoscopy with documented signs or symptoms, or has inflammatory bowel disease on targeted medical therapy or hereditary polyposis syndrome; or an ASC guideline regarding weight or health conditions prevents use of an ASC.Within 25 miles
Medication-related inpatient monitoring: The procedure requires discontinuing medications, such as antiarrhythmics or antiseizure medication, requiring preoperative or postoperative inpatient monitoring or treatment.
Substance or medication interaction: The individual uses substances or medications, such as cocaine, amphetamines, monoamine oxidase inhibitors, or alcohol, that may interact with the anticipated anesthetic regimen or cause withdrawal syndrome.
Prior hemodynamic instability: There is a history of significant hemodynamic instability during a prior surgical procedure that is considered a future procedural risk.
Pediatric age: The individual is age 17 years or younger.17 years and younger
Concurrent hospital-level service: The procedure is performed during the same operative session as an additional service that requires a hospital outpatient department.Same operative session
ASA status: The individual's ASA Physical Status Classification is III or higher.ASA PS III or higher
See policy guidelines for ASA classifications.
Morbid obesity: The individual's body mass index is over 40.BMI >40
Bleeding disorder: A bleeding disorder requires replacement factor or special infusion products to correct a coagulation defect.
Complex anticoagulation management is anticipated.
Transfusion is anticipated.
Sickle cell disease: The individual has sickle cell disease.
Increased cardiovascular risk: Clinical documentation shows increased cardiovascular risk due to symptomatic arrhythmia despite medication; coronary artery disease; recent coronary stenting or angioplasty; recent CVA or TIA; recent MI; an ICD; an implanted pacemaker; mechanical cardiovascular support; peripheral vascular disease; ongoing myocardial ischemia; severe or resistant hypertension; uncompensated CHF, NYHA class III or IV; or moderate or severe valvular heart disease or cardiomyopathy.
Recent-event and hypertension thresholds are specified in the policy.
Prolonged surgery: The surgery is prolonged.>3 hours
Advanced liver disease: The individual has advanced liver disease.MELD score >8
Uncontrolled diabetes or recurrent metabolic events: The individual has uncontrolled diabetes or recurrent diabetic ketoacidosis or severe hypoglycemia.HgbA1c >8%, recurrent DKA, or severe hypoglycemia
Advanced kidney disease: The individual has end-stage renal disease or stage 4 or 5 chronic kidney disease.ESRD or CKD stage 4 or 5
Skin or wound infection: There is an incompletely treated skin or wound infection.
Pregnancy: The individual is pregnant.
Increased pulmonary risk: Pulmonary risk is increased because of an abnormal airway, prior difficult intubation, active respiratory infection, COPD, a condition associated with difficult airway, poorly controlled asthma, moderate-to-severe obstructive sleep apnea, ventilator dependence, or continuous supplemental oxygen use.
Pulmonary function and sleep-apnea thresholds are specified in the policy.
Anesthesia complication history: There is a personal or family history of an anesthesia complication such as malignant hyperthermia.
Aspiration risk: There is a documented history of achalasia or delayed gastric emptying disorder or gastroparesis that increases aspiration risk.
Neurologic risk: There is active multiple sclerosis, myasthenia gravis, or a severe motor disorder such as severe Parkinson's disease or other severe neurologic dysfunction.
Restraint requirement: A condition requires use of restraints.
History of total joint infection: The individual has a history of total joint infection.
Awaiting major organ transplant: The individual is awaiting a major organ transplant.
Procedure-specific complication risk: There is a risk of a procedure-specific complication.
Disability affecting ASC care: A documented disability makes receiving care in an ASC setting inappropriate.
Overnight recovery: The provider documents that overnight recovery is required because of a unique circumstance for the individual.Overnight recovery required

Medically Necessary Hospital Outpatient Site of Care

Hospital outpatient department use instead of an ASC may be medically necessary when ALL of the following are met.

Medically necessary hospital outpatient site of care

Procedure complexity: The procedure is of a level of complexity such that it may not be performed in a less intensive setting.
Service medical necessity: The service being performed is medically necessary.
Site-of-care criteria: The surgical site-of-care policy criteria are met.

Not Medically Necessary Hospital Outpatient Site of Care

Hospital outpatient department use instead of an ASC is not medically necessary when any listed disqualifying condition applies.

Not medically necessary conditions

Less intensive setting is safe: The procedure can be safely performed in a less intensive setting.
Prior authorization criteria not met: The specific service requires prior authorization and does not meet applicable policy criteria.
Site-of-care criteria not met: 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.

Prior authorization under this policy addresses the site of care only. The procedure itself may require separate prior authorization under the applicable medical policy. For hospital outpatient coverage, the service must also be medically necessary under applicable prior-authorization requirements and the applicable medical policy, unless the health plan does not require separate prior authorization for that service.

Use of a hospital outpatient department instead of an ASC is not medically necessary when the procedure can be safely performed in a less intensive setting.

The use of a hospital outpatient department for surgical services instead of an ASC or physician office is considered not medically necessary when the applicable hospital outpatient site-of-care criteria are not met.

Hospital outpatient site of care is not medically necessary when the procedure can be safely performed in a less intensive setting, when a specific service requiring prior authorization does not meet the applicable policy criteria, or when the surgical site-of-care criteria are not met.

Codes and Qualifying Site-of-Care Factors

CPT Codes Subject to Outpatient Hospital Site-of-Care ReviewCPT

44388	Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
44391	Colonoscopy through stoma; with control of bleeding, any method
44392	Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
44394	Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
44408	Colonoscopy through stoma; with decompression for pathologic distention, including placement of decompression tube, when performed
45330	Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45331	Sigmoidoscopy, flexible; with biopsy, single or multiple
45335	Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45338	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45347	Sigmoidoscopy, flexible; with placement of endoscopic stent, including pre- and post-dilation and guide wire passage, when performed

1–10 of 27

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HCPCS Codes Subject to Outpatient Hospital Site-of-Care ReviewHCPCS

G0104	Colorectal cancer screening; flexible sigmoidoscopy
G0105	Colorectal cancer screening; colonoscopy on individual at high risk
G0121	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Geographic ASC access

Geographic access criterionNo qualifying in-network ASC within 25 miles of the individual's residence

Facility requirementThe ASC must be able to provide the necessary care and have the necessary equipment

Alternative siteHospital outpatient department instead of an ASC or physician office

Age

Qualifying age17 years and younger

Site-of-care relevanceMay support hospital outpatient department use instead of an ASC or physician office

Authorization and Documentation Requirements

Prior Authorization

Request site-of-care authorization separately

Prior authorization under this policy addresses the site of care only. The procedure may require separate prior authorization under the applicable medical policy.

Prior Authorization

Meet hospital outpatient site-of-care criteria

When the specific service requires prior authorization, the request must meet the applicable policy criteria for the hospital outpatient site of care to be medically necessary. The service must also be medically necessary under applicable prior-authorization requirements and the applicable medical policy, unless the health plan does not require separate prior authorization.

Documentation Required

Site-of-Care Background

An ambulatory surgery center (ASC) is a same-day surgical facility outside the hospital setting and does not have inpatient beds. Whether hospital outpatient care is appropriate depends on the individual's health status, facility and geographic availability, specialty requirements, physician privileges, ASA physical status, and significant comorbidities. Hospital outpatient care may be appropriate when the individual has elevated anesthetic, cardiopulmonary, neurologic, aspiration, bleeding, metabolic, or other procedural risk, or when required ASC resources are unavailable.

Key Definitions

Ambulatory surgery center (ASC)

DefinitionA health care facility offering same-day surgical care outside the hospital setting

Inpatient bedsThe facility does not have inpatient beds

SponsorshipThe entity may or may not be sponsored by a hospital

ASA Physical Status Classification

DefinitionA preoperative health-grading system maintained by the American Society of Anesthesiologists

Hospital outpatient relevanceASA III or higher is a criterion supporting hospital outpatient site of care under this policy

Clinical use

Policy Summary

PayerRegence

PolicySurgical Site of Care - Colonoscopy and Sigmoidoscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewSep 1, 2026

Next Review DateAugust 1, 2027

Key ActionSubmit history and physical or chart notes, the ASA score when applicable, and documentation supporting the specific site-of-care criterion.

SourceLink

On This Page

Listed as a medically necessary hospital outpatient site-of-care criterion

Body mass index

Qualifying BMIBMI over 40

ConditionBody mass index is over 40

Site-of-care relevanceMay support hospital outpatient department use instead of an ASC or physician office

Prolonged surgery

Duration thresholdMore than 3 hours

CriterionProlonged surgery

Site-of-care relevanceMay support hospital outpatient department use instead of an ASC or physician office

Advanced liver disease

MELD thresholdMELD score greater than 8

ConditionAdvanced liver disease

Site-of-care relevanceMay support hospital outpatient department use instead of an ASC or physician office

Uncontrolled diabetes

HgbA1c thresholdHgbA1c greater than 8%

ConditionUncontrolled diabetes

Additional qualifying conditionsRecurrent diabetic ketoacidosis or severe hypoglycemia

Chronic obstructive pulmonary disease

FEV1 thresholdFEV1 less than 50%

ConditionChronic obstructive pulmonary disease (COPD)

Site-of-care relevanceListed as a factor increasing pulmonary risk

Poorly controlled asthma

FEV1 thresholdFEV1 less than 80% despite medical management

ConditionPoorly controlled asthma

Site-of-care relevanceListed as a factor increasing pulmonary risk

Moderate obstructive sleep apnea

AHI or RDI rangeGreater than 15 and less than 30

ConditionModerate obstructive sleep apnea

MeasurementApnea hypopnea index (AHI) or respiratory disturbance index (RDI)

Severe obstructive sleep apnea

AHI or RDI thresholdGreater than 30 per hour

ConditionSevere obstructive sleep apnea

MeasurementApnea hypopnea index (AHI) or respiratory disturbance index (RDI)

Severe hypertension

Blood-pressure thresholdGreater than 180/110

ConditionSevere hypertension

Alternative hypertension criterionResistant hypertension not responsive to three antihypertensive medications

Recent coronary intervention

Drug-eluting stentPlaced within 1 year

Bare-metal stentPlaced within 90 days

Plain angioplastyPerformed within 90 days

Recent cerebrovascular event

Cerebrovascular eventCVA or TIA within the past 3 months

CVACerebrovascular accident

TIATransient ischemic attack

Recent myocardial infarction

Timing criterionMI within the past 3 months

EventMyocardial infarction

Site-of-care relevanceListed under increased cardiovascular risk

Submit required clinical records

Submit the clinical records needed to determine whether the policy criteria are met. Incomplete submissions could impact the review and decision outcome.

History and physical or chart notes
American Society of Anesthesiologists (ASA) score, as applicable
Clinical documentation supporting the specific site-of-care criterion
Applicable medical policy clinical documentation for services requiring separate prior authorization
The Surgical Site of Care Additional Information form is recommended when faxing a preauthorization request

Documentation Required

Document diagnostic indications and site-of-care qualification

For diagnostic colonoscopy or diagnostic sigmoidoscopy, submit documentation of signs and/or symptoms. Also submit documentation supporting the qualifying site-of-care criterion for the requested hospital outpatient setting.

Denial Risk

Risk of denial without a qualifying criterion

Use of a hospital outpatient department instead of an ambulatory surgery center or physician office is considered not medically necessary when none of the medical-necessity criteria is met.

Denial Risk

Incomplete diagnostic or procedure records may affect review

A diagnostic colonoscopy or diagnostic sigmoidoscopy requires documentation of signs and/or symptoms. Hospital outpatient coverage also requires the procedure itself to be medically necessary under applicable prior-authorization requirements and the applicable medical policy, unless the health plan does not require separate prior authorization for the procedure.

Denial Risk

Hospital outpatient setting must be medically necessary

The hospital outpatient department site of care is not medically necessary when the procedure can be safely performed in a less intensive setting. A denial may also result when the required prior authorization or surgical site-of-care criteria are not met.

ASA I-II individuals might be appropriate candidates for ASC care, while ASA III and above may not be

ASA Physical Status Classification System

PurposeA classification system with definitions and ASA-approved examples used with other factors to aid in predicting perioperative risks

ASA IIISubstantive functional limitations or one or more moderate to severe diseases; examples include COPD, morbid obesity, and compensated cirrhosis

ASA IVSevere systemic disease that is a constant threat to life; examples include recent MI, CVA, TIA, or CAD/stents