Title: Site of Service Guidelines for Certain Outpatient Surgical Procedures
Policy Effective Date: October 1, 2015 (except Colorado effective Nov. 1, 2015; and Iowa and Illinois effective Dec. 1, 2015)
In an effort to minimize out-of-pocket costs for United Healthcare members and to improve cost efficiencies for the overall health care system, United Healthcare is implementing prior authorization guidelines that aim to encourage more cost-effective sites of service for certain outpatient surgical procedures, when medically appropriate.
These procedures will require prior authorization if performed in an outpatient hospital setting. No prior authorization will be required if they are performed at an ambulatory surgery center. Coverage determinations will consider availability of a participating network facility, specialty requirements, physician privileges and whether a patient has an individual need for access to more intensive services.
These guidelines are effective for dates of service on or after Oct. 1, 2015, in most states, except for Colorado, where the effective date is Nov. 1, 2015, and for Illinois and Iowa, where the effective date is Dec. 1, 2015. Effective dates are determined by the member’s state of residence.
The prior authorization requirement applies to commercial and exchange membership.
The guidelines apply to the following codes and procedures:
Abdominal Paracentesis – 49083
Carpal Tunnel Surgery – 64721
Cataract Surgery – 66821, 66982, 66984
Hernia Repair – 49585, 49587, 49650, 49651, 49652, 49653, 49654, 49655
Liver Biopsy – 47000
Tonsillectomy & Adenoidectomy – 42821, 42826
Upper & Lower Gastrointestinal Endoscopy – 43235, 43239, 43249, 45378, 45380, 45384, 45385
Urologic Procedures – 50590, 52000, 52005, 52204, 52224, 52234, 52235, 52260, 52281, 52310, 52332, 52351, 52352, 52353, 52356, 57288
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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