Outpatient Surgical Procedures – Site of Service

UnitedHealthcare? Commercial Utilization Review Guideline

OUTPATIENT SURGICAL PROCEDURES ? SITE OF SERVICE

Guideline Number: URG-11.05

Effective Date: November 1, 2019

Instructions for Use

Table of Contents

Page

COVERAGE RATIONALE ............................................. 1

DOCUMENTATION REQUIREMENTS............................. 2

DEFINITIONS .......................................................... 2

APPLICABLE CODES ................................................. 3

REFERENCES ........................................................... 3

GUIDELINE HISTORY/REVISION INFORMATION ........... 4

INSTRUCTIONS FOR USE .......................................... 4

Related Commercial Policies Cosmetic and Reconstructive Procedures Femoroacetabular Impingement Syndrome Hysterectomy for Benign Conditions Light and Laser Therapy Manipulation Under Anesthesia Obstructive Sleep Apnea Treatment Occipital Neuralgia and Headache Treatment Oral Surgery: Non-Pathologic Excisional Procedures Percutaneous Vertebroplasty and Kyphoplasty Sodium Hyaluronate Temporomandibular Joint Disorders

Community Plan Policy Outpatient Surgical Procedures ? Site of Service

COVERAGE RATIONALE

UnitedHealthcare members may choose to receive surgical procedures in an ambulatory surgical center (ASC) or other locations. We are conducting site of service medical necessity reviews, however, to determine whether the outpatient hospital department is medically necessary, in accordance with the terms of the member's benefit plan. If the outpatient hospital department is not considered medically necessary, this location will not be covered under the member's plan.

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria: Advanced liver disease (MELD Score > 8) Advance surgical planning determines an individual requires overnight recovery and care following a surgical

procedure Anticipated need for transfusion Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a

coagulation defect Brittle Diabetes Cardiac arrhythmia (symptomatic arrhythmia despite medication) Chronic obstructive pulmonary disease (COPD) (FEV1 3 hours) Resistant hypertension (Poorly Controlled)

Outpatient Surgical Procedures ? Site of Service

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 Severe valvular heart disease Sleep apnea (moderate to severe Obstructive Sleep Apnea (OSA) Uncompensated chronic heart failure (CHF) (NYHA class III or IV)

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following: There is no geographically accessible ambulatory surgical center that has the necessary equipment for the

procedure; or There is no geographically accessible ambulatory surgical center available at which the individual's physician has

privileges; or An ASC's specific guideline regarding the individual's weight or health conditions that prevents the use of an ASC

Planned Surgical Procedures List

Site of service medical necessity reviews will be conducted for the following surgical procedures only when performed in an outpatient hospital setting (see Applicable Codes List).

DOCUMENTATION REQUIREMENTS

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

CPT Codes*

Required Clinical Information

Outpatient Surgical Procedures ? Site of Service

Medical notes documenting all of the following:

History Physical examination including patient weight and co-morbidities Surgical plan Physician privileging information related to the need for the use of the hospital

outpatient department American Society of Anesthesiologists (ASA) score, as applicable

Refer to the Applicable Codes section for a complete

list of codes and their descriptions.

In addition to the above, additional documentation requirements may apply for the following codes. Review the below listed policies in conjunction with the guidelines in this document. For 15576, refer to the Coverage Determination Guideline titled Cosmetic and

Reconstructive Procedures For 17106, 17107 and 17108, refer to the Medical Policy titled Light and Laser

Therapy For 20551, 20552, 20553, 29800 and 29804, refer to the Medical Policy titled

Temporomandibular Joint Disorders For 20605, 20606, 20610, 201611, refer to the Medical Benefit Drug Policy titled

Sodium Hyaluronate For 22513 and 22514, refer to the Medical Policy titled Percutaneous

Vertebroplasty and Kyphoplasty For 23700 and 27570, refer to the Medical Policy titled Manipulation Under

Anesthesia For 29914, 29915 and 29916, refer to the Medical Policy titled Femoroacetabular

Impingement Syndrome For 42145, refer to the Medical Policy titled Obstructive Sleep Apnea Treatment For 58263, refer to the Medical Policy titled Hysterectomy for Benign Conditions For 62281, refer to the Medical Policy titled Occipital Neuralgia and Headache

Treatment

*For code descriptions, see the Applicable Codes section.

DEFINITIONS

ASA Physical Status Classification System Risk Scoring Tool: While anesthesia providers use this scale to indicate one's overall physical health or "sickness" preoperatively, it is regarded by hospitals, law firms, accrediting boards and other healthcare groups as a scale to predict risk and thus decide if a patient should have or should have had an operation. To predict operative risk, age and obesity, the nature and severity of the operative procedure, selection of anesthetic techniques, the competency of the surgical team (surgeon, anesthesia providers and assisting

Outpatient Surgical Procedures ? Site of Service

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UnitedHealthcare Commercial Utilization Review Guideline

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staff), duration of surgery or anesthesia, availability of equipment, medicine, blood, implants and especially the level of post-operative care etc. are often far more important than multiple ASA classification.

Brittle Diabetes: Diabetes that is difficult to control due to symptoms such as (1) predominant hyperglycemia with recurrent ketoacidosis, (2) predominant hypoglycemia, and (3) mixed hyper- and hypoglycemia.

Obstructive Sleep Apnea (OSA): Severity is defined as: Moderate for AHI or RDI 15 and 30. Severe for AHI or RDI > 30/hr.

Poorly Controlled: Requiring three or more drugs to control blood pressure.

APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

CPT/HCPCS Codes Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Code List

REFERENCES

American Heart Association. Classes of Heart Failure. Available at: . Accessed August 2, 2019.

American Society of Anesthesiologists (ASA) Physical Status Classification System.

American Society of Anesthesiologists. Guidelines for ambulatory anesthesia and surgery. October 17, 2018.

American Society of Anesthesiologists. Guidelines for patient care in anesthesiology. October 26, 2016.

Bilimoria K, Liu Y, Paruch J, et al. Development and evaluation of the Universal ACS NSQIP Surgical Risk Calculator: a decision aide and informed consent tool for patients and surgeons. J Am Coll Surg. 2013 November; 217(5): 833? 842.e3.

Brolin TJ, Mulligan RP, Azar FM, et al. Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study. J Shoulder Elbow Surg. 2017;26(2):204-8.

Cancienne JM, Brockmeier SF, Gulotta LV, et al. Ambulatory total shoulder arthroplasty: a comprehensive analysis of current trends, complications, readmissions, and costs. J Bone Joint Surg Am. 2017;99(8):629- 37.

Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun 15; 5(3):263-76.

Friedman L S. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc. 2010; 121: 192?205.

Goyal N, Chen AF, Padgett SE, et al. Otto Aufranc Award: a multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clin Orthop. 2017;475(2):364-7.

Joshi G, Ahmad S; Riad W. et al. Selection of obese patients undergoing ambulatory surgery: a systematic review of the literature. Anesthesia & Analgesia. November 2013; 117(5): 1082?1091.

Joshi G, Ankichetty P, Gan T, and Chung F. Society for Ambulatory Anesthesia Consensus Statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesthesia & Analgesia: November 2012; 115(5): 1060?1068.

Joshi G; Chung F; Vann Mary Ann, et al. Society for Ambulatory Anesthesia Consensus Statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia & Analgesia. December 2010; 111(6): 1378?1387.

Lovald S, Ong K, Lau E, et al. Patient selection in outpatient and short-stay total knee arthroplasty. J Surg Orthop Adv. 2014 Spring;23(1):2-8.

Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010 May;85(5):483-500.

Outpatient Surgical Procedures ? Site of Service

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Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology. 2013 Dec;119(6):1310-21.

National Kidney Foundation. Clinical update on hyperkalemia. A chronic risk for CKD patients and a potential barrier to recommended CKD treatment. . Accessed August 2, 2019.

Neighborhood Health Plan (NHP). Prior Authorization Requirements. . Accessed August 2, 2019.

Orthopedic Certification. Pathways to excellence in patient care. Joint Commission.

Sankar A, Johnson SR, Beattie WS, et al. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth. 2014 Sep;113(3):424-32.

United HealthCare Advance Notification List. To view the most current and complete Advance Notification List, including procedure codes and associated services. . Accessed August 2, 2019.

GUIDELINE HISTORY/REVISION INFORMATION

Date 11/01/2019

Action/Description Related Policies Updated list of related policies

Coverage Rationale Replaced language indicating "certain elective procedures performed in a hospital

outpatient department are considered medically necessary for an individual who meets any of the criteria [listed in the policy]" with "certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets any of the criteria [listed in the policy]" Revised medical necessity criteria; added criterion requiring "[the individual is] less than 19 years of age" Revised language pertaining to the inability to access an ambulatory surgical center: o Replaced reference to "elective surgical procedure" with "planned surgical

procedure" o Added language to clarify any one of the listed situations are considered

medically necessary Revised language pertaining to the Planned Surgical Procedures List to indicate

site of service medical necessity reviews will be conducted for the surgical procedures [listed in the policy] only when performed in an outpatient hospital setting

Documentation Requirements Added requirement for medical notes documenting physician privileging

information related to the need for the use of the hospital outpatient department

Applicable Codes Reformatted content Added 1,105 CPT/HCPCS codes (see list for details)

Supporting Information Updated References section to reflect the most current information Archived previous policy version URG-11.04

INSTRUCTIONS FOR USE

This Utilization Review Guideline provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this guideline, please check the member specific benefit plan document and any applicable federal or state mandates. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Utilization Review Guideline is provided for informational purposes. It does not constitute medical advice.

UnitedHealthcare may also use tools developed by third parties, such as the MCGTM Care Guidelines, to assist us in administering health benefits. UnitedHealthcare Utilization Review Guidelines are intended to be used in connection

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UnitedHealthcare Commercial Utilization Review Guideline

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with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

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