Site of Service: Select Surgical Procedures · Site of Service: Select Surgical Procedures...

UTILIZATION MANAGEMENT GUIDELINE 11.01.524

Site of Service: Select Surgical Procedures

Effective Date: June 1, 2018

Last Revised: April 15, 2018

Replaces: N/A

RELATED MEDICAL POLICIES:

2.02.507 Coronary Angiography for Known or Suspected Coronary Artery

Disease

7.01.48 Autologous Chondrocyte Implantation for Focal Articular Cartilage

Lesions

7.01.78 Autografts and Allografts in the Treatment of Focal Articular Cartilage

Lesions

7.01.108 Artificial Intervertebral Disc: Cervical Spine

7.01.503 Reduction Mammaplasty for Breast Related Symptoms

7.01.546 Spinal Cord and Dorsal Root Ganglion Stimulation

7.01.549 Knee Arthroscopy in Adults

7.01.551 Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy,

Laminotomy, Laminectomy

7.01.554 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

7.01.558 Rhinoplasty

7.01.559 Sinus Surgery

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COVERAGE GUIDELINES | CODING | RELATED INFORMATION | REFERENCES | HISTORY

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Introduction

Surgery may safely be performed in various settings. Some of the common settings used are an

inpatient hospital or medical center, an off campus outpatient hospital or medical center, an on

campus outpatient hospital or medical center, an ambulatory surgical center, or a doctors office.

Costs for surgical procedures may vary among these different settings. To encourage the use of

the most safe and appropriate, cost effective sites of service for certain medically necessary

outpatient surgical procedures, prior authorization is required for the site of service for the

surgical procedures listed below.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The

rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for

providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can

be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a

service may be covered.

https://www.premera.com/medicalpolicies/2.02.507.pdfhttps://www.premera.com/medicalpolicies/2.02.507.pdfhttps://www.premera.com/medicalpolicies/7.01.48.pdfhttps://www.premera.com/medicalpolicies/7.01.48.pdfhttps://www.premera.com/medicalpolicies/7.01.78.pdfhttps://www.premera.com/medicalpolicies/7.01.78.pdfhttps://www.premera.com/medicalpolicies/7.01.108.pdfhttps://www.premera.com/medicalpolicies/7.01.503.pdfhttps://www.premera.com/medicalpolicies/7.01.503.pdfhttps://www.premera.com/medicalpolicies/7.01.546.pdfhttps://www.premera.com/medicalpolicies/7.01.549.pdfhttps://www.premera.com/medicalpolicies/7.01.551.pdfhttps://www.premera.com/medicalpolicies/7.01.551.pdfhttps://www.premera.com/medicalpolicies/7.01.554.pdfhttps://www.premera.com/medicalpolicies/7.01.558.pdfhttps://www.premera.com/medicalpolicies/7.01.559.pdf

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Coverage Guidelines

We will review the site of service for medical necessity for certain elective surgical procedures.

Site of service is defined as the location where the surgical procedure is performed, such as an

off campus-outpatient hospital or medical center, an on campus-outpatient hospital or medical

center, an ambulatory surgical center, or an inpatient hospital or medical center.

Site of Service for

Elective Surgical

Procedures

Medical Necessity

Medically necessary sites

of service:

Off campus-outpatient

hospital/medical center

On campus-outpatient

hospital/medical center

Ambulatory surgical

center

Certain elective surgical procedures will be covered in the most

appropriate, safe, and cost effective site. These are the

preferred medically necessary sites of service for certain

elective surgical procedures.

Inpatient hospital/medical

center

Certain elective surgical procedures will be covered in the most

appropriate, safe, and cost-effective site. This site is

considered medically necessary only when the patient has a

clinical condition which puts him or her at increased risk for

complications including any of the following (this list may not

be all inclusive):

Anesthesia Risk

o ASA classification III or higher (see definition)

o Personal history of complication of anesthesia

o Documentation of alcohol dependence or history of

cocaine use

o Prolonged surgery (>3 hours)

Cardiovascular Risk

o Uncompensated chronic heart failure (NYHA class III or IV)

o Recent history of myocardial infarction (MI) (

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Site of Service for

Elective Surgical

Procedures

Medical Necessity

placed < 1 year or angioplasty 8)**

Pulmonary Risk

o Chronic obstructive pulmonary disease (COPD) (FEV1

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This guideline applies to any of the following elective surgical procedures (see the

individual noted policies for the medical necessity criteria for the procedure):

BREAST SURGERY

EAR, NOSE, THROAT (ENT) SURGERY

HEART SURGERIES

KNEE SURGERY

SPINE SURGERY

SITE OF SERVICE

Breast Surgeries

Reduction Mammaplasty for Breast Related Symptoms 7.01.503

Reduction mammaplasty

Ear, Nose, Throat (ENT) Surgeries

Rhinoplasty 7.01.558

Primary rhinoplasty and/or elevation of nasal tip

Primary rhinoplasty; complete (external parts including bony pyramid)

Primary rhinoplasty; including major septal repair

Secondary rhinoplasty; minor revision (small amount of nasal tip work)

o Secondary rhinoplasty; intermediate revision (bony work with osteotomies)

Secondary rhinoplasty; major revision (nasal tip work and osteotomies)

Sinus Surgery 7.01.559

Nasal/sinus endoscopy with partial, anterior, ethmoidectomy

o Nasal/sinus endoscopy with total, anterior/posterior, ethmoidectomy

Nasal/sinus endoscopy with maxillary antrostomy

o Nasal/sinus endoscopy with maxillary antrostomy with removal of tissue from maxillary

sinus

Nasal/sinus endoscopy with frontal sinus exploration with or without removal of tissue

Nasal/sinus endoscopy with sphenoidotomy

o Nasal/sinus endoscopy with sphenoidotomy with removal of tissue from the sphenoid

sinus

https://www.premera.com/medicalpolicies/7.01.503.pdfhttps://www.premera.com/medicalpolicies/7.01.558.pdfhttps://www.premera.com/medicalpolicies/7.01.559.pdf

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Ear, Nose, Throat (ENT) Surgeries Nasal/sinus endoscopy with balloon dilation of maxillary sinus ostium

o Nasal/sinus endoscopy with balloon dilation of frontal sinus ostium

Nasal/sinus endoscopy with balloon dilation of sphenoid sinus ostium

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 7.01.554

Palatopharyngoplasty (UPPP)

Heart Surgeries

Coronary Angiography for Known or Suspected Coronary Artery Disease 2.02.507

Coronary angiography without left heart catheterization

o Coronary and bypass graft angiography without left heart catheterization

Coronary angiography with right heart catheterization

o Coronary and bypass graft angiography with right heart catheterization

Coronary angiography with left heart catheterization

o Coronary and bypass graft angiography with left heart catheterization

Coronary angiography with right and left heart catheterization

o Coronary and bypass graft angiography with right and left heart catheterization

Knee Surgeries

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

7.01.78

Open osteochondral knee allograft

Open osteochondral knee autograft

o Arthroscopic osteochondral knee autograft

Open osteochondral ankle allograft

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 7.01.48

Knee arthroscopy for harvesting of cartilage (chondrocyte cells)

Implantation of autologous cultured chondrocytes

Knee Arthroscopy in Adults 7.01.549

Knee arthroscopy lavage and drainage for infection

Knee arthroscopy with lateral release

Knee arthroscopy for removal of loose or foreign body

Knee arthroscopy limited synovectomy

o Knee arthroscopy major synovectomy, 2 or more compartments

Knee arthroscopy chondroplasty (debridement/shaving of articular cartilage)

https://www.premera.com/medicalpolicies/7.01.554.pdfhttps://www.premera.com/medicalpolicies/2.02.507.pdfhttps://www.premera.com/medicalpolicies/7.01.78.pdfhttps://www.premera.com/medicalpolicies/7.01.48.pdfhttps://www.premera.com/medicalpolicies/7.01.549.pdf

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Knee Surgeries Knee arthroscopy abrasion arthroplasty or multiple drilling or microfracture

Knee arthroscopy with meniscectomy (medial and lateral)

o Knee arthroscopy with meniscectomy (medial or lateral)

Knee arthroscopy with meniscus repair (medial or lateral)

o Knee arthroscopy with meniscus repair (medial and lateral)

Knee arthroscopy with lysis of adhesions with or without manipulation

Knee arthroscopy anterior cruciate ligament (ACL) repair or reconstruction

o Knee arthroscopy posterior cruciate ligament repair or reconstruction

Spine Surgeries

Artificial Intervertebral Disc: Cervical Spine 7.01.108

Implantation of anterior cervical total disc arthroplasty

o Implantation of anterior cervical total disc arthroplasty, second level

o Revision/Replacement of anterior cervical total disc arthroplasty

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy,

Laminectomy 7.01.551

Lumbar laminectomy with exploration and/or decompression of spinal cord and/or

cauda equina 2 vertebral segments

o Lumbar laminectomy with exploration and/or decompression of spinal cord and/or cauda

equina > 2 vertebral segments

Lumbar laminectomy with removal of abnormal facets and/or pars inter-articularis with

decompression of cauda equina and nerve roots for spondylolisthesis

Lumbar laminotomy (hemilaminectomy) with decompression of nerve roots, including

partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc

o Lumbar laminotomy (hemilaminectomy) with decompression of nerve roots, including

partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each

additional space

Lumbar laminotomy (hemilaminectomy) with decompression of nerve roots, including

partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc,

reexploration, single interspace

o Lumbar laminotomy (hemilaminectomy) with decompression of nerve roots, including

partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc,

https://www.premera.com/medicalpolicies/7.01.108.pdfhttps://www.premera.com/medicalpolicies/7.01.551.pdf

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Spine Surgeries rexploration, single interspace; each additional lumbar interspace

Lumbar laminectomy, facetectomy and foraminotomy (unilateral or bilateral with

decompression of spinal cord, cauda equina and/or nerve root[s]), single vertebral

segment

o Lumbar laminectomy, facetectomy and foraminotomy (unilateral or bilateral with

decompression of spinal cord, cauda equina and/or nerve root[s]), single vertebral

segment; each additional segment

Lumbar transpedicular approach with decompression of spinal cord, equina and/or nerve

root(s) single segment;

o Lumbar transpedicular approach with decompression of spinal cord, equina and/or nerve

root(s) single segment; each additional segment

Laminectomy with rhizotomy; 1 or 2 segments

o Laminectomy with rhizotomy; more than 2 segments

Laminectomy with section of spinal accessory nerve

Lumbar laminectomy for excision or evacuation of extradural, intraspinal lesion other

than neoplasm

o Lumbar laminectomy for excision of intradural, intraspinal lesion other than neoplasm

Spinal Cord and Dorsal Root Ganglion Stimulation 7.01.546

Percutaneous epidural implantation of neurostimulator electrode array

o Percutaneous removal of spinal neurostimulator electrode array(s)

Percutaneous revision including replacement of spinal neurostimulator electrode

array(s)

Laminectomy for epidural implantation of neurostimulator electrodes, plate/paddle(s)

o Laminectomy/laminotomy removal neurostimulator electrodes, plate/paddle(s)

Laminectomy/laminotomy revision including replacement of spinal neurostimulator

electrode, plate/paddle(s)

Insertion or replacement of spinal neurostimulator pulse generator or receiver

o Revision or removal of implanted spinal neurostimulator pulse generator or receiver

https://www.premera.com/medicalpolicies/7.01.546.pdf

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Spine Surgeries Implantable neurostimulator pulse generator, any type

Implantable neurostimulator each electrode

Implantable neurostimulator radiofrequency receiver

o Radiofrequency external transmitter for use with implantable neurostimulator

radiofrequency receiver

Rechargeable, implantable neurostimulator pulse generator, single array

o Nonrechargable implantable neurostimulator pulse generator, single array

Rechargeable, implantable neurostimulator pulse generator, dual array

o Nonrechargable implantable neurostimulator pulse generator, dual array

Coding

Code Description

Breast Surgery

CPT

19318 Reduction mammaplasty

Ear, Nose, Throat (ENT) Surgery

CPT

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar

cartilages, and/or elevation of nasal tip

30420 Rhinoplasty, primary; including major septal repair

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)

31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)

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Code Description

31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy;

31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue

from maxillary sinus

31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of

tissue from frontal sinus, when performed

31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy

31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the

sphenoid sinus

31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon

dilation), transnasal or via canine fossa

31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon

dilation)

31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon

dilation)

42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Heart Surgery

CPT

93454 Catheter placement in coronary artery(s) for coronary angiography, including

intraprocedural injection(s) for coronary angiography, imaging supervision and

interpretation;



interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free

arterial, venous grafts) including intraprocedural injection(s) for bypass graft

angiography



interpretation; with right heart catheterization



interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free

arterial, venous grafts) including intraprocedural injection(s) for bypass graft

angiography and right heart catheterization



interpretation; with left heart catheterization including intraprocedural injection(s) for

left ventriculography, when performed

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Code Description



interpretation; with left heart catheterization including intraprocedural injection(s) for

left ventriculography, when performed, catheter placement(s) in bypass graft(s)

(internal mammary, free arterial, venous grafts) with bypass graft angiography



interpretation; with right and left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed



interpretation; with right and left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed, catheter placement(s) in bypass

graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Knee Surgery

CPT

27412 Autologous chondrocyte implantation, knee

27415 Osteochondral allograft, knee, open

27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of

autograft[s])

28446 Open osteochondral autograft, talus (includes obtaining graft[s])

29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes

harvesting of the autograft[s])

29871 Arthroscopy, knee, surgical; for infection, lavage and drainage

29873 Arthroscopy, knee, surgical; with lateral release

29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg,

osteochondritis dissecans fragmentation, chondral fragmentation)

29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection)

(separate procedure)

29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial

or lateral)

29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where

necessary) or multiple drilling or microfracture

29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any

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Code Description

meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty),

same or separate compartment(s), when performed

29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any

meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty),

same or separate compartment(s), when performed

29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation

(separate procedure)

29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or

reconstruction

29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or

reconstruction

HCPCS

J7330 Autologous cultured chondrocytes, implant

S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

Spine Surgery

CPT

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional

interspace, cervical (List separately in addition to code for primary procedure)

0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior

approach, each additional interspace, cervical (List separately in addition to code for

primary procedure)

0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with

end plate preparation (includes osteophytectomy for nerve root or spinal cord

decompression and microdissection), cervical, three or more levels

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with


decompression and microdissection); single interspace, cervical

22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with


decompression and microdissection); second level, cervical (List separately in addition

to code for primary procedure)

22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior

approach, single interspace; cervical

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Code Description

63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda

equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2

vertebral segments; lumbar, except for spondylolisthesis

63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with

decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill

type procedure)

63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda

equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more

than 2 vertebral segments; lumbar

63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial

facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1

interspace, lumbar


facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each

additional interspace, cervical or lumbar (List separately in addition to code for primary

procedure)


facetectomy, foraminotomy and/or excision of herniated intervertebral disc,

reexploration, single interspace; lumbar


facetectomy, foraminotomy and/or excision of herniated intervertebral disc,

reexploration, single interspace; each additional lumbar interspace (List separately in

addition to code for primary procedure)

63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with

decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral

recess stenosis]), single vertebral segment; lumbar

63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with

decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral

recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic,

or lumbar (List separately in addition to code for primary procedure)

63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve

root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet,

or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve

root(s) (eg, herniated intervertebral disc), single segment; each additional segment,

thoracic or lumbar (List separately in addition to code for primary procedure)

63185 Laminectomy with rhizotomy; 1 or 2 segments

63190 Laminectomy with rhizotomy; more than 2 segments

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Code Description

63191 Laminectomy with section of spinal accessory nerve

63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm,

extradural; lumbar

63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar

63650 Percutaneous implantation of neurostimulator electrode array, epidural

63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

63661 Removal of spinal neurostimulator electrode percutaneous array(s), including

fluoroscopy, when performed

63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or

laminectomy, including fluoroscopy, when performed

63663 Revision including replacement, when performed, of spinal neurostimulator electrode

percutaneous array(s), including fluoroscopy, when performed

63664 Revision including replacement, when performed, of spinal neurostimulator electrode

plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when

performed

63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct

or inductive coupling

63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver

HCPCS

L8679 Implantable neurostimulator, pulse generator, any type

L8680 Implantable neurostimulator electrode, each

L8682 Implantable neurostimulator radiofrequency receiver

L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator

radiofrequency receiver

L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes

extension

L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes

extension

L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes

extension

L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes

extension

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS

codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Page | 14 of 15

Related Information

Definition of Terms

American Society of Anesthesiologists (ASA) Score:

ASA 1 A normal healthy patient.

ASA 2 A patient with mild systemic disease.

ASA 3 A patient with severe systemic disease.

ASA 4 A patient with severe systemic disease that is a constant threat to life.

ASA 5 A moribund patient who is not expected to survive

New York Heart Association (NYHA) Classification:

Class I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath

when walking, climbing stairs etc.

Class II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during

ordinary activity.

Class III Marked limitation in activity due to symptoms, even during less-than-ordinary

activity, eg, walking short distances (20100 m).Comfortable only at rest.

Class IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound

patients

Place of Service (Professional Claims Codes):

Off-Campus-Outpatient Hospital A portion of an off-campus hospital provider based

department which provides diagnostic, therapeutic (both surgical and nonsurgical), and

rehabilitation services to sick or injured persons who do not require hospitalization or

institutionalization. (Code 19)

Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic,

therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the

supervision of physicians to patients admitted for a variety of medical conditions. (Code 21)

On Campus-Outpatient Hospital A portion of a hospitals main campus which provides

diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or

injured persons who do not require hospitalization or institutionalization. (Code 22)

Ambulatory Surgical Center A freestanding facility, other than a physicians office, where

surgical and diagnostic services are provided on an ambulatory basis. (Code 24)

Page | 15 of 15

References

None

History

Date Comments 03/01/18 New Utilization Management Guideline, approved February 13, 2018, effective June 1,

2018.

04/15/18 Anterior Cervical Spine Decompression and Fusion in Adults was removed from the

Site of Service program. CPT codes 22551, 22552, 22554, and 22585 removed from

policy.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The

Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and

local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review

and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit

booklet or contact a member service representative to determine coverage for a specific medical service or supply.

CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2018 Premera

All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when

determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to

the limits and conditions of the member benefit plan. Members and their providers should consult the member

benefit booklet or contact a customer service representative to determine whether there are any benefit limitations

applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

037338 (07-2016)

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(Chinese): Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu dandaa. Guyyaawwan murteessaa taan beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu dandaa. Kaffaltii irraa bilisa haala taeen afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa. Franais (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermdiaire de Premera Blue Cross. Le prsent avis peut contenir des dates cls. Vous devrez peut-tre prendre des mesures par certains dlais pour maintenir votre couverture de sant ou d'aide avec les cots. Vous avez le droit d'obtenir cette information et de laide dans votre langue aucun cot. Appelez le 800-722-1471 (TTY: 800-842-5357). Kreyl ayisyen (Creole): Avi sila a gen Enfmasyon Enptan ladann. Avi sila a kapab genyen enfmasyon enptan konsnan aplikasyon w lan oswa konsnan kouvti asirans lan atrav Premera Blue Cross. Kapab genyen dat ki enptan nan avi sila a. Ou ka gen pou pran kk aksyon avan sten dat limit pou ka kenbe kouvti asirans sante w la oswa pou yo ka ede w avk depans yo. Se dwa w pou resevwa enfmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357). Deutsche (German): Diese Benachrichtigung enthlt wichtige Informationen. Diese Benachrichtigung enthlt unter Umstnden wichtige Informationen bezglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie knnten bis zu bestimmten Stichtagen handeln mssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357). Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357). Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357). Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso pu contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).

(Japanese): Premera Blue Cross

800-722-1471 (TTY: 800-842-5357) (Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY: 800-842-5357) . (Lao): . Premera Blue Cross. . . . 800-722-1471 (TTY: 800-842-5357). (Khmer):

Premera Blue Cross

800-722-1471 (TTY: 800-842-5357) (Punjabi): . Premera Blue Cross . . , , 800-722-1471 (TTY: 800-842-5357).

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. Premera Blue Cross .

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)800-842-5357 TTY( 800-722-1471 .

Polskie (Polish): To ogoszenie moe zawiera wane informacje. To ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub zakresu wiadcze poprzez Premera Blue Cross. Prosimy zwrcic uwag na kluczowe daty, ktre mog by zawarte w tym ogoszeniu aby nie przekroczy terminw w przypadku utrzymania polisy ubezpieczeniowej lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej informacji we wasnym jzyku. Zadzwocie pod 800-722-1471 (TTY: 800-842-5357). Portugus (Portuguese): Este aviso contm informaes importantes. Este aviso poder conter informaes importantes a respeito de sua aplicao ou cobertura por meio do Premera Blue Cross. Podero existir datas importantes neste aviso. Talvez seja necessrio que voc tome providncias dentro de determinados prazos para manter sua cobertura de sade ou ajuda de custos. Voc tem o direito de obter esta informao e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Romn (Romanian): Prezenta notificare conine informaii importante. Aceast notificare poate conine informaii importante privind cererea sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue Cross. Pot exista date cheie n aceast notificare. Este posibil s fie nevoie s acionai pn la anumite termene limit pentru a v menine acoperirea asigurrii de sntate sau asistena privitoare la costuri. Avei dreptul de a obine gratuit aceste informaii i ajutor n limba dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357). P (Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY: 800-842-5357). Faasamoa (Samoan): Atonu ua iai i lenei faasilasilaga ni faamatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei faasilasilaga o se fesoasoani e faamatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Faamolemole, ia e iloilo faalelei i aso faapitoa oloo iai i lenei faasilasilaga taua. Masalo o lea iai ni feau e tatau ona e faia ao lei aulia le aso ua taua i lenei faasilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo oloo e iai i ai. Oloo iai iate oe le aia tatau e maua atu i lenei faasilasilaga ma lenei famatalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Espaol (Spanish): Este Aviso contiene informacin importante. Es posible que este aviso contenga informacin importante acerca de su solicitud o cobertura a travs de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura mdica o ayuda con los costos. Usted tiene derecho a recibir esta informacin y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357). (Thai): Premera Blue Cross 800-722-1471 (TTY: 800-842-5357) (Ukrainian): . Premera Blue Cross. , . , , . . 800-722-1471 (TTY: 800-842-5357). Ting Vit (Vietnamese): Thng bo ny cung cp thng tin quan trng. Thng bo ny c thng tin quan trng v n xin tham gia hoc hp ng bo him ca qu v qua chng trnh Premera Blue Cross. Xin xem ngy quan trng trong thng bo ny. Qu v c th phi thc hin theo thng bo ng trong thi hn duy tr bo him sc khe hoc c tr gip thm v chi ph. Qu v c quyn c bit thng tin ny v c tr gip bng ngn ng ca mnh min ph. Xin gi s 800-722-1471 (TTY: 800-842-5357).

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