CurrentUnitedHealthcarePolicy MP.15.10

Screening Colonoscopy Procedures - Site of Service

Defines medical necessity criteria for performing planned preventive screening colonoscopy in a hospital outpatient department (versus ambulatory surgical center) for UnitedHealthcare Individual Exchange members (all states except TX and WI). Applies to site-of-service reviews only for listed procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicyScreening Colonoscopy Procedures - Site of Service

Policy CodePolicy MP.15.10

Change TypeTemplate update / administrative

Effective DateMay 1, 2025

Next Review Date

Key ActionConduct site-of-service medical necessity reviews for planned preventive screening colonoscopies billed from hospital outpatient departments and expect potential noncoverage if the hospital setting is not medically necessary per the policy criteria.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Rocky Mountain Health Plans membership and removed language indicating the policy does not apply to Colorado; template update.

1policy applies to Individual Exchange product only (except TX and WI)

>=1clinical conditions listed that justify hospital outpatient department for screening colonoscopy

14CPT/HCPCS and ICD-10 codes explicitly listed

Medically Necessary Criteria — Screening Colonoscopy Site-of-Service

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Medically necessary — Planned preventive screening colonoscopy in hospital outpatient department

A planned preventive screening colonoscopy performed in a hospital outpatient department is considered medically necessary when ANY of the following patient conditions or circumstances are met:

ANY of the following

Advanced liver disease (MELD Score > 8)MELD Score > 8
Anticipated need for transfusion
Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect
Cardiac arrhythmia (symptomatic arrhythmia despite medication)
Chronic obstructive pulmonary disease (COPD) with FEV1 < 50%FEV1 < 50%
Coronary artery disease (CAD) or peripheral vascular disease (PVD) with ongoing cardiac ischemia requiring medical management or recent drug eluting stent placement within 1 yearDES within 1 year
Developmental stage or cognitive status warranting use of a hospital outpatient department
End stage renal disease receiving peritoneal or hemodialysis or hyperkalemia above reference range
History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) with recent event < 3 monthsrecent event < 3 months
History of myocardial infarction (MI) with recent event < 3 monthsrecent event < 3 months
Individuals with drug eluting stents placed within one year or bare metal stents or plain angioplasty within 90 days unless aspirin and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesiaDES within 1 year; BMS or angioplasty within 90 days
Continuation of aspirin and antiplatelet agents by agreement of surgeon, cardiologist, and anesthesia may allow ASC use
Ongoing evidence of myocardial ischemia
Poorly controlled asthma (FEV1 < 80% despite medical management)FEV1 < 80%
Resistant hypertension (poorly controlled)
Severe valvular heart disease
Sleep apnea: moderate to severe obstructive sleep apnea (OSA)
OSA severity per AASM: moderate AHI/RDI ≥15–≤30; severe >30/hr
Uncompensated chronic heart failure (NYHA Class III or IV)
NYHA classification I–IV described in policy
Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia

Medically necessary — inability to access ASC

A planned preventive screening colonoscopy performed in a hospital outpatient department is considered medically necessary when there is inability to access an ambulatory surgical center (ASC) due to ANY one of the following:

ANY of the following

No geographically accessible ambulatory surgical center that has the necessary equipment for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, and nonstandard scopes required to perform specialized procedures)
Excludes surgeon-preferred or proprietary instruments or hardware sets
An ASC's specific guideline regarding the individual's weight or health conditions that prevents the use of an ASC

Applicable Procedure and Diagnosis Codes

Covered/Applicable Procedure Codes (site-of-service review applies when performed in outpatient hospital)CPT|HCPCS

45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45380	Colonoscopy, flexible; with biopsy, single or multiple
45381	Colonoscopy, flexible; with directed submucosal injection(s), any substance
45384	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
G0105	Colorectal cancer screening; colonoscopy on individual at high risk
G0121	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Applicable ICD-10 Diagnosis Codes (screening / family history)ICD-10

Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings
Z12.10	Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11	Encounter for screening for malignant neoplasm of colon
Z12.12	Encounter for screening for malignant neoplasm of rectum
Z80.0	Family history of malignant neoplasm of digestive organs
Z83.710	Family history of adenomatous and serrated polyps
Z83.711	Family history of hyperplastic colon polyps
Z83.718	Other family history of colon polyps
Z83.719	Family history of colon polyps, unspecified

1–10 of 12

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What Providers Must Do / Expect

Prior Authorization

Site-of-service medical necessity review required when performed in outpatient hospital

UnitedHealthcare will conduct site-of-service medical necessity reviews for planned preventive screening colonoscopies billed from an outpatient hospital department. Reviews apply when services are billed with any of the following procedure codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121. Providers should expect review and potential noncoverage if the outpatient hospital department is not medically necessary based on policy criteria.

Applicable procedure codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121

Documentation Required

Medical record documentation may be required

Medical records documentation may be requested to determine whether the member meets the clinical criteria for coverage; submission of documentation does not guarantee coverage. Refer to the protocol titled “Medical Records Documentation Used for Reviews” for required documentation expectations.

Denial Risk

Denial if hospital outpatient department not medically necessary

If the outpatient hospital department is not considered medically necessary under the member’s benefit plan, services performed in that location will not be covered. Providers submitting claims for hospital outpatient settings should be aware of this denial risk if site-of-service criteria are not met.

Clinical and Administrative Context

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether planned preventive screening colonoscopies billed from a hospital outpatient department are medically necessary rather than appropriate to perform in an ambulatory surgical center (ASC). If the outpatient hospital department is not considered medically necessary under the member's benefit plan, services performed at that location will not be covered. These reviews apply to the listed procedure codes when billed from an outpatient hospital setting and do not change coverage determinations for diagnostic colonoscopies, which are considered under nonpreventive benefits (see related Outpatient Surgical Procedures - Site of Service policy).

A planned preventive screening colonoscopy performed in a hospital outpatient department is considered medically necessary when the individual has clinical conditions or circumstances that increase anesthesia or procedural risk, or when there is an inability to access an ASC with the necessary equipment or support. Examples of clinical conditions that justify the hospital outpatient setting include: advanced liver disease (MELD score > 8); anticipated need for transfusion; bleeding disorders requiring replacement factor, blood products, or special infusion products; symptomatic cardiac arrhythmia despite medication; COPD with FEV1 < 50%; coronary artery or peripheral vascular disease with ongoing ischemia or recent drug-eluting stent placement; developmental or cognitive status requiring hospital-level care; end-stage renal disease on dialysis or with hyperkalemia; recent cerebrovascular accident or transient ischemic attack (< 3 months); recent myocardial infarction (< 3 months); recent stent/angioplasty without agreed continuation of antiplatelet therapy (for example, DES within 1 year; BMS or angioplasty within 90 days); ongoing myocardial ischemia; poorly controlled asthma (FEV1 < 80% despite medical management); resistant hypertension; severe valvular heart disease; moderate to severe obstructive sleep apnea per AASM criteria; uncompensated chronic heart failure (NYHA Class III or IV); and uncontrolled diabetes with recurrent DKA or severe hypoglycemia.

A hospital outpatient department is also considered medically necessary when the ASC cannot be accessed or does not have necessary equipment or support for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, or nonstandard scopes required for specialized procedures) or when an ASC's specific weight or health condition guidelines preclude use of the ASC. This exclusion does not extend to surgeon-preferred or proprietary instrument sets.

Policy Summary

PayerUnitedHealthcare

PolicyScreening Colonoscopy Procedures - Site of Service

Policy CodePolicy MP.15.10

Change TypeTemplate update / administrative

Effective DateMay 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Screening Colonoscopy Procedures - Site of Service

Medically Necessary Criteria — Screening Colonoscopy Site-of-Service

Applicable Procedure and Diagnosis Codes

What Providers Must Do / Expect

Clinical and Administrative Context

Numeric / Clinical Thresholds Referenced

Defined Terms

Policy Updates

Screening Colonoscopy Procedures - Site of Service

Medically Necessary Criteria — Screening Colonoscopy Site-of-Service

Applicable Procedure and Diagnosis Codes

What Providers Must Do / Expect

Clinical and Administrative Context

Numeric / Clinical Thresholds Referenced

Defined Terms

Also See

Policy Updates