Clinical UM Guideline

This document addresses procedures performed in the ambulatory or outpatient surgery centers.

Ambulatory surgery refers to surgical or invasive procedures performed by qualified providers in ambulatory or dedicated surgical suites with pre-procedural and immediate post-procedural care on the same day or observation admissions without hospitalization (Patient Selection Criteria for Ambulatory [Same Day] Surgery VHA Handbook).

Note: Please see the following related documents for additional information:

• CG-MED-83 Site of Care: Specialty Pharmaceuticals

Note: The medical necessity of the procedure may be separately reviewed against the appropriate criteria.

Medically Necessary:

The use of an outpatient or ambulatory surgery center (ASC) facility, rather than an office-based setting, is considered medically necessary when any of the following criteria are met:

1. The procedure must be of a level of complexity that it may not be performed in a less intensive setting such as an office-based setting, but also not so complex as to require immediate access to specific services of a medical center/hospital setting or post-operative recovery in an inpatient facility. For example the procedure’s complexity requires one of the following, including but not limited to:
   1. Need for anesthesia or sedation beyond topical anesthesia, digital block, or local anesthesia with concomitant need for monitoring of physiologic parameters beyond intermittent checks of vital signs; or
   2. Need for recovery period of significant duration beyond the capacity of a physician’s office;
      OR
2. The individual has clinical conditions which may compromise the safety of an office-based procedure, including but not limited to:
   1. Conditions which require enhanced monitoring, medications or a prolonged recovery period; or
   2. Increased risk for complication due to severe comorbidity, such as that evidenced by an American Society of Anesthesiologist’s (ASA) class III or higher physical status.

Not Medically Necessary:

All other uses of outpatient or ASC facility, rather than an office-based setting, are considered not medically necessary.

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

While hospitals continue to provide essential services for serious illness, much health care takes place in the ambulatory setting. More than half of all surgery in the United States is performed on an ambulatory basis (Patient Selection Criteria for Ambulatory [Same Day] Surgery VHA Handbook). Ambulatory (or outpatient) surgery provides an efficient and flexible means to provide many surgical or invasive procedures without requiring an inpatient hospital admission. With advances in healthcare delivery and the advent of new technologies, the list of such services continues to expand. While it is important to emphasize that both the complexity of the procedure and the individual’s clinical conditions may compromise the safety of an office-based procedure, we provide the following examples of procedures which would generally not warrant use of an ambulatory or outpatient surgery center:

1. Minor aspiration or injection procedures;
2. Minor skin procedures such as acne surgery, incision and drainage, debridement, paring or cutting, biopsy, shaving, excision, destruction, exfoliation or electrolysis;
3. Minor nail procedures such as trimming, debridement, evacuation of subungual hematoma or excision of nail and nail matrix;
4. Implantation or removal of contraceptive capsules or pellets;
5. Simple repair of superficial wounds;
6. Removal of superficial foreign bodies including protruding surgical hardware (for example: k-wires, pins);
7. Arthrocentesis, aspiration and/or injection procedures with or without image guidance;
8. Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative);
9. Closed treatment of phalangeal, metatarsal, sesamoid, calcaneal, talus fracture, or tarsal bone fracture; without manipulation;
10. Venipuncture services;
11. Maxillary impression for palatal prosthesis;
12. Insertion of pin-retained palatal prosthesis;
13. Artificial insemination; intra-cervical or intra-uterine sperm washing for artificial insemination;
14. Application of surface (transcutaneous) neurostimulator;
15. Chemodenervation of salivary glands or muscle(s) (for example: for blepharospasm, hemifacial spasm);
16. Destruction by neurolytic agent; peripheral nerve or branch;
17. Assorted patch, scratch, prick and intradermal allergy tests.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology-Head and Neck Surgery Position Statement: Ambulatory Procedures (2021). Available at: https://www.entnet.org/resource/position-statement-ambulatory-procedures/. Accessed on September 6, 2023.
2. American Medical Association. Revised statement on patient safety principles for office-based surgery utilizing moderate sedation/analgesia. Updated on September 1, 2019. Available at: https://www.facs.org/about-acs/statements/118-office-based-surgery. Accessed on September 6, 2023.
3. American Society of Anesthesiologists. Guidelines for Office-Based Anesthesia. Approved October 13, 1999, and last amended October 23, 2019. Available at: https://www.asahq.org/standards-and-guidelines/guidelines-for-office-based-anesthesia. Accessed on September 6, 2023.
4. Medicare Claims Processing Manual. Chapter 14 - Ambulatory Surgical Centers. (Rev. 03/24/2023). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Accessed on September 6, 2023.

Ambulatory or Outpatient Surgery Center Procedures    
Ambulatory Surgery Center Procedures
Outpatient Surgery Center Procedures

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan's or line of business's members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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