UTILIZATION MANAGEMENT GUIDELINE – 11.01.524 Site of Service: Select Surgical Procedures Effective Date: July 2, 2020 Last Revised: July 31, 2020 Replaces: N/A

RELATED MEDICAL POLICIES: 7.01.15 Meniscal Allografts and Other Meniscal Implants 7.01.48 Autologous Chondrocyte Implantation for Focal Articular Cartilage

Lesions 7.01.78 Autografts and Allografts in the Treatment of Focal Articular Cartilage

Lesions7.01.101 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

7.01.108 Artificial Intervertebral Disc: Cervical Spine 7.01.533 Reconstructive Breast Surgery/Management of Breast Implants 7.01.551 Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy,

Laminotomy, Laminectomy 7.01.559 Sinus Surgery RELATED INTERQUAL SUBSETS: • Angiogram coronary +/- Left Heart Catheterization • Arthroscopy or Arthroscopically Assisted Surgery, Knee • Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee • Cardiac Catheterization Right Heart with Coronary Angiogram • Rhinoplasty • Spinal Cord Stimulator (SCS) Insertion

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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 doctor’s 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

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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.

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

o Poorly controlled, resistant hypertension* o Recent history of cerebrovascular accident (< 3 months) o Increased risk for cardiac ischemia (drug eluting stent

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 Reconstructive Breast Surgery/Management of Breast Implants 7.01.533 • Reduction mammaplasty Reduction Mammaplasty for Breast Related Symptoms 7.01.503 • Reduction mammaplasty

Ear, Nose, Throat (ENT) Surgeries Rhinoplasty (InterQual) • 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 total, anterior/posterior, ethmoidectomy, including frontal

sinus exploration, with removal of tissue from frontal sinus when performed Nasal/sinus endoscopy with total, anterior/posterior, ethmoidectomy, including

sphenoidectomy Nasal/sinus endoscopy with total, anterior/posterior, ethmoidectomy, including

sphenoidectomy, with removal of tissue from the sphenoid sinus • Nasal/sinus endoscopy with maxillary antrostomy

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

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Ear, Nose, Throat (ENT) Surgeries • 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

• 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 Nasal/sinus endoscopy with balloon dilation of frontal and sphenoid sinus ostia

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 7.01.101 • Palatopharyngoplasty (UPPP)

Heart Surgeries Coronary Angiography for Known or Suspected Coronary Artery Disease (InterQual) • 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 7.01.570 • Open osteochondral knee allograft

o Arthroscopic osteochondral knee allograft • Open osteochondral knee autograft

o Arthroscopic osteochondral knee autograft • Open osteochondral ankle allograft Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 7.01.569 • Knee arthroscopy for harvesting of cartilage (chondrocyte cells)

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Knee Surgeries • Implantation of autologous cultured chondrocytes Knee Arthroscopy in Adults (InterQual) • 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) • 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 Meniscal Allografts and Other Meniscal Implants 7.01.15 • Knee arthroscopy with meniscus repair (medial or lateral)

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

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Spine Surgeries • 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, 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 (InterQual) • Percutaneous epidural implantation of neurostimulator electrode array

o Percutaneous removal of spinal neurostimulator electrode array(s)

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Spine Surgeries 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 • 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

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Code Description 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)

31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed

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

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

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

31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy

31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus

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 (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa

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

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

31298 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia

42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Heart Surgery

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

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

93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 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

93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 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

93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 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

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Code Description 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])

29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

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 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

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Code Description 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)

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord 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

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

63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

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Code Description 63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial

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

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

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

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).

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, eg, 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 (20–100 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 hospital’s main campus which provides

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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 physician’s office, where surgical and diagnostic services are provided on an ambulatory basis. (Code 24)

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.

06/19/18 Coding update, removed codes 0375T, L8679, L8680, L8682, L8683, L8685, L8686, L8687, and L8688. Added 7.01.15, 7.01.533, and 7.01.557 to Related Policies.

06/26/18 Added details for two additional policies (7.01.533 and 7.01.557) under the breast surgery section of Coverage Guidelines. Added details for an additional policy (7.01.15) under the knee surgery section of Coverage Guidelines.

08/25/18 Minor update, removed all reference to policy 7.01.557.

01/24/19 Coding update, added CPT codes 29867, 31253, 31257, 31259, 31298.

03/01/19 Annual Review, approved February 5, 2019. No changes to coverage guidelines.

01/01/20 Coding update, revised descriptors for CPT codes 31295, 31296, 31297, and 31298.

04/01/20 Archive policy, approved March 10, 2020. This policy will be archived effective July 2, 2020.

06/10/20 Interim Review, approved June 9, 2020, effective July 2, 2020. This policy will no longer be archived on July 2 – changes for this date listed. The following procedures will still apply to this policy; however, InterQual medical necessity criteria will be used for the following procedures: coronary angiography, knee arthroscopy, rhinoplasty, spinal cord and dorsal ganglion root stimulation. Refer to InterQual for medical necessity

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Date Comments criteria (see Related Policies); this policy will determine site of service when inpatient exception may be considered.

08/01/20 Update Related Policies. 7.01.569 is now 7.01.48; 7.01.570 is now 7.01.78.

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). ©2020 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.

Discrimination is Against the Law

LifeWise Health Plan of Washington complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. LifeWise does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

LifeWise: • Provides free aids and services to people with disabilities to communicate

effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible

electronic formats, other formats) • Provides free language services to people whose primary language is not

English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that LifeWise has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-6396, Fax 425-918-5592, TTY 800-842-5357 Email AppealsDepartmentInquiries@LifeWiseHealth.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Getting Help in Other Languages

This Notice has Important Information. This notice may have important information about your application or coverage through LifeWise Health Plan of Washington. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-592-6804 (TTY: 800-842-5357).

አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ LifeWise Health Plan of Washington ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-592-6804 (TTY: 800-842-5357) ይደውሉ።

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Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de LifeWise Health Plan of Washington. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez le 800-592-6804 (TTY: 800-842-5357).

Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè LifeWise Health Plan of Washington. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-592-6804 (TTY: 800-842-5357).

Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch LifeWise Health Plan of Washington. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, 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 800-592-6804 (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 LifeWise Health Plan of Washington. 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 800-592-6804 (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 LifeWise Health Plan of Washington. Daytoy ket mabalin dagiti importante a petsa iti daytoy

(Arabic): ةالعربي 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 امةھ ماتولعم اراإلشع ھذا يحوي . أو طلبك وصخصب مةمھ اتمولعم عارشإلا ھذا ويحي قد

mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga اللخ من ھاعلي لوالحص تريد التي التغطية LifeWise Health Plan of Washington. قدawan ti bayadanyo. Tumawag iti numero nga 800-592-6804 (TTY: 800-842-5357).

على اظلحفل نةعيم يخراوت في إجراء التخاذ اجتحت قدو . اإلشعار ذاھ في مھمة يخراوت ھناك تكون ةدمساعوال تالوملمعا ھذه على ولحصال لك يحق .يفكالتال دفع في دةاعسملل أو يةحصلا تكطيتغ

فةلكت أية بدتك دون تكغلب (TTY: 800-842-5357) 6804-592-800بـصل ات .

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 LifeWise Health Plan of Washington 提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有

權利免費以您的母語得到本訊息和幫助。請撥電話 800-592-6804 (TTY: 800-842-5357)。

037336 (07-2016)

Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso LifeWise Health Plan of Washington. 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 800-592-6804 (TTY: 800-842-5357).

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@LifeWiseHealth.com

้

日本語 (Japanese):この通知には重要な情報が含まれています。この通知には、 LifeWise Health Plan of Washington の申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要

な日付をご確認ください。健康保険や有料サポートを維持するには、特定

の期日までに行動を取らなければならない場合があります。ご希望の言語

による情報とサポートが無料で提供されます。 800-592-6804 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 LifeWise Health Plan of Washington 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다 . 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 800-592-6804 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ LifeWise Health Plan of

Washington. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນ້ີ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າ ເນີ ນການຕາມກໍ ານົດເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລ່ື ອງຄ່າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນ້ີ ແລະ ຄວາມ ວຍເຫຼື ອເປັ ນພາສາຂອງທ່ານໂດຍບໍ່ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-592-6804

(TTY: 800-842-5357).

ភាសាែខមរ (Khmer):

ມູ ຮັ ສິ

ມູ ຂໍ້

ສໍ

ຈ່

ວັ

ມູ ຂໍ້ ມີ ໝັ

ຊ່

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Health Plan of Washington. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-592-6804 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через LifeWise Health Plan of Washington. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-592-6804 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, LifeWise Health Plan of Washington, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-592-6804 (TTY: 800-842-5357).

Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Health Plan of Washington. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de

េសចកតជី ូ នដំ ងេនះមានព័ ី

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់ តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ជូ ត៌ ណឹ នដ

រងរបស់អន

LifeWise Health Plan of Washington ។ របែហលជាមាន កាលបរ ិ ឆ ំ ់ េចទសខានេនៅ

មានយ៉ា ំ ់ ត ងសខាន។ េសចក ំណឹងេនះរបែហល

កតាមរយៈ

ងេសចកត ី នដណងេនះ។ អករបែហលជារតវការបេញញសមតភាព ដល់ ណត់ ំ ឹ ន ូ ច ថ កំ ជូ កន ុ determinadas fechas para mantener su cobertura médica o ayuda con los អន ៃថងជាកចបាសនានា េដ ី ឹ ុ ៉ ប់ ុខភាពរបស់ ក ឬរបាក់ costos. Usted tiene derecho a recibir esta información y ayuda en su idioma ់ ់ ើមបនងរកសាទកការធានារា រងស

ក sin costo alguno. Llame al 800-592-6804 (TTY: 800-842-5357). ជ ំ យេចញៃថ កមានសិ េដាយមិ ុ ើ ូ ូ នអសលយេឡយ។ សមទ

ទធ នួ ល។ អន នួ ិ ួលព័ ៌ ិងជំ ន ុងភាសារបស ទទ តមានេនះ ន យេនៅក អន ់

800-592-6804 (TTY: 800-842-5357)។

រស័

ਅੰ

ਜਾਬੀ (Punjabi): paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋ ਿਟਸ ਿਵਚ LifeWise Health Plan of tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng LifeWise

Health Plan of Washington. Maaaring may mga mahalagang petsa dito sa Washington ਵਲ ਤੁ ਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹਤਵਪੂ ੋ ਸਕਦੀ ਹਾਡੀ ਕਵਰੇ ੱ ਰਨ ਜਾਣਕਾਰੀ ਹ

ពទ

paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang ਹੈ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਂ ਹਨ. ਜੇ ੁ ੇ ੱ ਖਣੀ ਹੋ ੇ mga itinakdang panahon upang mapanatili ang iyong pagsakop sa . ਇਸ ਨ ਸਕਦੀਆ ਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰ ਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ੱ ੁ ੋ ਤਾਂ ਤੁ ੰ ੂ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ਇਛਕ ਹ ਹਾਨ ੱ ਝ ਖਾਸ

ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag ਕਦਮ ਚੁਕਣ ਦੀ ਲੜ ਹੋ ਸਕਦੀ ਹ ੈ,ਤੁ ੰ ੂ ਮੁ ੱ ਚ ਤੇ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ੱ ੋ ਹਾਨ ਫ਼ਤ ਿਵ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਮਦਦ sa 800-592-6804 (TTY: 800-842-5357). ਪ੍ਰ ੈਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-592-6804 (TTY: 800-842-5357).

ਪੰ

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang

ไทย (Thai): ประกาศน ้ีมีข้อมลูสําคญั ประกาศน ้ีอาจมีข้อมลูที่สําคญัเกี่ยวกบัการการสมคัรหรือขอบเขตประกนั

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين . ميباشد ھمم اطالعات یوحا يهمالعا اين

สขุภาพของคณุผ่าน LifeWise Health Plan of Washington และอาจมีกําหนดการในประกาศ طريق از ماش ای مهبي وششپ يا و تقاضا LifeWise Health Plan of Washington به .باشدี น جهتو يهمالعا اين در ھمم ھای خيتار يا تان بيمه وششپ حقظ برای است کنمم ماش . يدماين کمک คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกนัสขุภาพของคณุ

اجتياح صیاخ کارھای امانج برای صیمشخ ھای خيتار به تان، انیمدر ھای زينهھ پرداخت درหรือการช่วยเหลือที่มีค่าใช้จ่าย คณุมีสิทธิที่จะได้รับข้อมลูและความช่วยเหลือน ้ีในภาษาของคณุโดยไม่ม ีباشيد داشته . رايگان ورط به ودخ انزب به را مکک و اطالعات اين که داريد را اين حق ماش

(ค่าใช้จ่าย โทร 800-592-6804 (TTY: 800-842-5357 مارهش با اطالعات سبک برای . نماييد دريافت 800-592-6804 . اييد نم برقرار استم ) 5357-842-800 مارهباش اس تم TTY کاربران(

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