CurrentUnitedHealthcarePolicy SURGERY 107.21

Office-Based Procedures Site of Service

Defines medical necessity criteria and prior authorization requirements for performing elective surgical procedures in an ambulatory surgical center versus an office setting for UnitedHealthcare Oxford members.

Policy Summary

PayerUnitedHealthcare

PolicyOffice-Based Procedures Site of Service

Policy CodePolicy SURGERY 107.21

Change TypeRoutine reviewclarified (no material change)

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization for listed procedures if they are performed outside an office setting.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

RequiredPrior authorization

Multiple specialtiesApplicable codes

ACS/ASAGuidance referenced

07/01/2025Effective date

Coverage Criteria for Site-of-Service

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ASC medical necessity criteria: Bleeding disorder that would cause a significant risk of morbidity; Allergy to local anesthetic; Developmental stage or cognitive status warranting use of an ambulatory surgical center; Presence of complications and comorbid disease that would cause office-based procedure to be unsafe or unsuitable; Failed office-based procedure attempts due to body habitus, abnormal anatomy, or technical difficulties; Inability to access an office setting because there is no geographically accessible in-network provider or there is no geographically accessible office that has the necessary equipment for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes such as duodenoscope or ureteroscope).N/A

Surgeon-preferred or proprietary instruments, instrument sets, or hardware sets are specifically excluded as reasons to require ASC.

Applicable Codes and Coding Considerations

Dermatology CPT codesCPT

11402	Excision, benign lesion including margins, trunk, arms or legs; excised diameter 1.1 to 2.0 cm
11403	Excision, benign lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm
11404	Excision, benign lesion including margins, trunk, arms or legs; excised diameter 3.1 to 4.0 cm
11406	Excision, benign lesion including margins, trunk, arms or legs; excised diameter over 4.0 cm
11420	Excision, benign lesion including margins, hands, feet; genitalia; excised diameter 0.5 cm or less
11421	Excision, benign lesion including margins, scalp, neck, hands, feet; genitalia; excised diameter 0.6 to 1.0 cm
11422	Excision, benign lesion including margins, scalp, neck, hands, feet; genitalia; excised diameter 1.1 to 2.0 cm
11423	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
11424	Excision, benign lesion including margins, hands, feet; genitalia; excised diameter 3.1 to 4.0 cm
11426	Excision, benign lesion including margins, scalp, neck, hands, feet; genitalia; excised diameter over 4.0 cm

1–10 of 11

1/2

General surgery / Muscular-Skeletal / Neurologic CPT codesCPT

19000	Puncture aspiration of cyst of breast
20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscles
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles
27096	Injection procedure for sacroiliac joint; anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed
64479	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level
64490	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64493	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
62270	Spinal puncture, lumbar, diagnostic
62321	Injection(s) of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance

Neurologic / Obstetrics-Gynecology / Respiratory CPT codesCPT

64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64635	Destruction by neurolytic agent; paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
57460	Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix
31579	Laryngoscopy; flexible or rigid telescopic, with stroboscopy (only flexible to be performed in office setting)

Geographic/access threshold

ThresholdNo geographically accessible in-network provider or no geographically accessible office that has the necessary equipment for the procedure (examples: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes such as duodenoscope or ureteroscope)

Coverage implicationIf the inability to access an appropriately equipped or in-network office exists, ASC use for the procedure may be considered medically necessary

Equipment examplesFluoroscopy; laser; ocular equipment; operating microscope; nonstandard scopes (e.g., duodenoscope, ureteroscope)

ExclusionSurgeon-preferred or proprietary instruments, instrument sets, or hardware sets are specifically excluded as reasons to require ASC

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for procedures listed in the Applicable Codes section if not performed in an office setting.

Prior authorization required when procedure is performed outside an office setting

Denial Risk

Site-of-Service Denial Risk

If the ambulatory surgical center (ASC) is not considered medically necessary per the member-specific benefit plan document, services provided at that ASC will not be covered. Review the member's benefit plan terms to determine site-of-service medical necessity before scheduling.

ASC site-of-service denial risk if not medically necessary per benefit plan

Documentation Required

Medical Records May Be Requested for Review

Medical records and documentation may be required to assess whether the member meets the clinical criteria for coverage. Submission of records for review does not guarantee coverage; providers should reference the member-specific benefit plan and the protocol titled "Medical Records Documentation Used for Reviews."

Provide complete clinical records to support medical necessity review
Documentation may include history, physical exam, imaging, prior conservative treatment, and procedure notes

Note

Provider Responsibility: Verify Member Benefits

Benefit coverage is determined by the member-specific benefit plan document and applicable laws. This policy is for interpretation assistance and does not replace review of the member's plan or applicable mandates.

Check member-specific benefit plan and state/federal mandates before using this policy

Background and Rationale

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether use of an ambulatory surgical center (ASC) versus an office setting is medically necessary under the member's benefit plan. If an ASC is not considered medically necessary per the member's benefit plan, the ASC location will not be covered.

An elective procedure in an ASC is considered medically necessary when the member cannot access an office setting because there is no geographically accessible in‑network provider or no geographically accessible office with the necessary equipment (examples: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes such as duodenoscope or ureteroscope). The policy expressly excludes surgeon‑preferred or proprietary instruments, instrument sets, or hardware sets as reasons to require an ASC.

Clinical guidance referenced in this policy includes ACS and ASA principles for office‑based surgery patient selection, facility capabilities, and anesthesia considerations; providers should follow the member's benefit plan document and may be asked to provide medical records to support site‑of‑service determinations.

Definitions

Medically necessary ASC use — qualifying indications

Most actionable criterionBleeding disorder that would cause a significant risk of morbidity

Allergy considerationAllergy to local anesthetic

Patient factorsDevelopmental stage or cognitive status warranting use of an ambulatory surgical center

Clinical complexityPresence of complications and comorbid disease that would make an office-based procedure unsafe or unsuitable

Prior failed attemptsFailed office-based procedure attempts due to body habitus, abnormal anatomy, or technical difficulties

Policy Revision History

2025-07-01effectiveLatest

Policy effective date and routine review with no change to coverage guidelines; previous policy version SURGERY 107.20 archived.

2025-07-01archived_previous_version

Archived previous policy version SURGERY 107.20 as part of routine review.