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Site of service for outpatient surgical procedures policy

Our precertification program is aimed at minimizing members’ out-of-pocket costs and improving overall cost efficiencies. It requires that the more cost-effective site of service is used for certain outpatient surgical procures, when clinically appropriate. Elective surgical procedures identified in this program should be performed in an ambulatory surgical center (ASC) or office setting unless the medical necessity criteria below is met.

 

When determining if the setting is cost effective for an elective procedure, consider the following:

 

  • Any state or federal requirements
  • Physician privileges at in-network ASC
  • ASC capacity and capability
  • Geographic availability of in-network providers

Clinical rationale and documentation must be provided for review of medical necessity exceptions.

We may require precertification for the outpatient hospital site of service for the following elective procedures:

 

  • Carpal tunnel surgery
  • Complex wound repair
  • Cystourethroscopy
  • Hemorrhoidectomy
  • Hernia repair
  • Hysteroscopy
  • Intranasal dermatoplasty
  • Septoplasty
  • Skin tissue transfer or rearrangement
  • Subcutaneous soft tissue excision
  • Tonsillectomy for those aged 12 and older 

We will not require precertification for the above services if they’re performed in an ambulatory surgical facility or an office, and all other plan criteria is met.

 

Certain elective surgical procedures on the participating provider precertification list may include additional review for the appropriateness of the outpatient hospital site of service in addition to the medical necessity criteria required for the procedure itself:

 

  • Artificial disc surgery: cervical
  • Autologous chondrocyte implantation (Carticel)
  • Blepharoplasty, canthopexy, canthoplasty
  • Breast reconstruction
  • Breast reduction, mammoplasty
  • Chiari malformation decompression surgery
  • Cochlear device and/or implantation
  • Dorsal column [lumbar] neurostimulators: trial or implantation
  • Endoscopic nasal balloon dilation
  • Excision, excessive skin including lipectomy and abdominoplasty
  • Functional endoscopic sinus Surgery (FESS)
  • Hip surgery to repair impingement syndrome
  • Kyphectomy
  • Laminectomy and laminotomy
  • Lipectomy
  • Osseointegrated implant
  • Osteochondral allograft/knee
  • Shoulder arthroplasty
  • Spinal fusion
  • Uvulopalatopharyngoplasty
  • Venous ligation

A member’s clinical presentation for outpatient surgery may be appropriate for an alternate site of care or a lower acuity setting. We consider the use of a hospital outpatient facility medically necessary for members who meet one or more of the criteria below:

 

  • American Society of Anesthesiologists (ASA) Physical Status classification III or higher1
  • Danger of airway compromise:
  1. History of obstructive sleep apnea or stridor; or 
  2. Persons with dysmorphic facial features, such as Pierre-Robin syndrome or Down syndrome; or
  3. Persons with oral abnormalities, such as small opening (less than 3 cm in adult); protruding incisors; high arched palate; macroglossia; tonsillar hypertrophy; or a non-visible uvula; or
  4. Persons with neck abnormalities, such as obesity involving the neck and facial structures, short neck, limited neck extension, spinal cord instability, decreased hyoid-mental distance (less than 3 cm in adult), neck mass, cervical spine disease or trauma, disorders of cranial nerves IX or X, tracheal deviation, or advanced rheumatoid arthritis; or
  5. Persons with jaw abnormalities, such as micrognathia, retrognathia, trismus, or significant malocclusion
  • Morbid obesity (BMI > 35 with comorbidities or BMI > 40)2
  • Pregnancy
  • Age less than 12 years
  • Prolonged surgery (>3 hrs.)
  • Metabolic, hepatic, or renal compromise including:
  1. Advanced liver disease (MELD Score > 8)3
  2. Poorly controlled diabetes (hemoglobin A1C > 7) 
  3. End-stage renal disease with hyperkalemia (serum potassium level of >5.0
  4. (mmol/L) or undergoing regularly scheduled peritoneal dialysis or hemodialysis
  • Active substance use-related disorders:
  1. Alcohol dependence (at risk for withdrawal syndrome)
  2. Current use of high-dose opioids4 (high risk for anesthesia complications)
  • High-risk cardiac status, including:
  1. History of myocardial infarction (MI) within 90 days prior to planned surgical procedure
  2. Ongoing evidence of myocardial ischemia
  3. Significant heart valve disease
  4. Cardiac arrhythmia (symptomatic arrhythmia despite medication)
  5. Hypertension resistant to concurrent use of three (3) or more prescription medications
  6. Uncompensated chronic heart failure (CHF) (NYHA class III or IV)
  • Coronary artery disease (CAD) or peripheral vascular disease (PVD) with one or more of the following:
  1. Ongoing cardiac ischemia requiring medical management
  2. Recent placement of drug eluting stent (DES) or bare metal stent (BMS) placed within 365 days prior to planned surgical procedure
  3. Angioplasty within 90 days prior to planned surgical procedure
  4. Active use of acetylsalicylic acid (ASA) or prescription anticoagulants
  • Comorbid neurological or neuromuscular conditions:
  1. History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) within 90 days of planned surgical procedure
  2. Uncontrolled epilepsy
  3. Cerebral palsy
  4. Multiple sclerosis
  5. Amyotrophic lateral sclerosis
  6. Traumatic brain injury with significant cognitive or behavioral issues
  7. Muscular dystrophy
  • Other respiratory and breathing related conditions:
  1. Sleep apnea (moderate to severe obstructive sleep apnea [OSA])5
  2. Unstable respiratory status: i. Poorly controlled asthma (FEV1 < 80% despite medical management); ii. Chronic obstructive pulmonary disease (COPD) (FEV1 < 50%); iii. Ventilator-dependentpatient (e.g., quadriplegia, paraplegia)
  • Hematologic conditions:
  1. Bleeding disorder requiring replacement factor, blood products or special infusion products to correct a coagulation defect (excluding DDAVP, which is not blood product)
  2. Significant thrombocytopenia (platelet count <100,000/microL)6
  3. Anticipated need for transfusion of blood (autologous or allogeneic) or blood products (e.g., platelets)
  4. Sickle cell disease
  5. History of disseminated intravascular coagulation (DIC)
  • Personal or family history of complication of anesthesia (i.e., malignant hyperthermia) or sedation
  • History of solid organ transplant requiring ongoing use of high-dose and/or multiple anti-rejection medication(s)
  • Other unstable or severe systemic diseases, intellectual disabilities or mental health conditions that would be best managed in an outpatient hospital setting

 

 

1 American Society of Anesthesiologists. ASA physical status classification system. December 13, 2020. Accessed November 5, 2021.

Obesity surgery. Number: 0157. Aetna.com. July 14, 2021. Accessed November 5, 2021.

3 Medscape. MELD Score – Age above 12 years. Accessed November 5, 2021.

U.S. Department of Health and Human Services Centers for Disease Control and Prevention. Calculating total daily dose of opioids for safer dosage. Accessed November 5, 2021.

Obstructive sleep apnea in adults. Number: 0004. Aetna.com. May 6, 2021. Accessed November 5, 2021.

6 Graetz, T, Nuttal, G, Shander, A. Perioperative blood management: Strategies to minimize transfusions. UpToDate.com. August 11, 2021. Accessed November 5, 2021.

 

 

 

 

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