Z-109-002

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

Z-109-002

Topic:

Outpatient Surgery Site of Care

Section:

Miscellaneous

Effective Date:

January 1, 2026

Issued Date:

December 22, 2025

Last Revision Date:

December 2025

Annual Review:

July 2025

Surgeries can be performed safely in various settings. This policy addresses individual and procedural factors influencing the need for potential urgent hospital-level care during outpatient procedures, thereby determining the appropriate site of service. Possible locations include off-campus and on-campus hospital outpatient departments, inpatient hospitals, ambulatory surgical centers (ASCs), and physician offices, each with varying costs. To ensure safe, timely and cost-effective care for specific surgical procedures, medical necessity will be reviewed, prioritizing the least expensive appropriate setting (physician's office, ASC, then outpatient hospital) unless clinical or geographic contraindications exist.

Policy Position

The procedures identified within this policy will be considered medically necessary when performed in the lowest appropriate setting unless the following clinical or geographic contraindications are met:

Age <18 years; or
Nearest in-network non-hospital outpatient facility with procedural capabilities is >25 miles from patient’s home; or
Anesthesia risk including ANY of the following;
- American Society of Anesthesiologists (ASA) Physical Status (PS) Classification IV or higher (see definition); or
- History of complications from anesthesia (e.g., malignant hyperthermia); or
- Alcohol dependence at risk for withdrawal syndrome; or
- Recent history of drug abuse (e.g., cocaine) (<3 months); or
- Prolonged surgery (>3 hours); or
- Known or suspected difficult airway; or
Increased cardiovascular risk, including but not limited to:
- Uncompensated chronic heart failure (NYHA class III or IV) (see definition); or
- Recent history of myocardial infarction (MI) (<6 months); or
- Poorly controlled, resistant hypertension; or
- Recent history of cerebrovascular accident or transient ischemic attack (<3 months); or
- Increased risk for cardiac ischemia (cardiac or vascular stent placed <1 year or angioplasty <90 days); or
- Cardiac arrhythmia that increases periprocedural or anesthesia risk; or
- Moderate or severe valvular heart disease; or
- Implantable cardioverter-defibrillator (ICD); or
- Mechanical cardiovascular support (e.g., left ventricular assist device [LVAD] or total artificial heart); or
Increased pulmonary risk, including but not limited to:
- Moderate to severe chronic obstructive pulmonary disease (COPD) (FEV1 <50% or 2 or more exacerbations in the past year); or
- Moderate or severe persistent asthma (FEV1 <80% despite treatment); or
- Moderate to severe obstructive sleep apnea (OSA) (AHI or RDI ≥15); or
- Dependent on a ventilator; or
- Dependent on continuous supplemental oxygen; or
Increased liver risk, including but not limited to:
- Advanced liver disease (MELD Score >8); or
Increased renal risk, including but not limited to:
- End stage renal disease on dialysis; or
Increased bleeding risk, including but not limited to:
- Bleeding disorder requiring replacement factor, blood products, DDAVP/desmopressin, or special infusion product; or
- Anticipated need for transfusion(s); or
Other
- Morbid obesity (BMI ≥40); or
- Brittle diabetes or HbA1C ≥ 8.5%; or
- Pregnancy; or
- Cannot transfer independently; or
- Known or suspected foreign body in the target organ or tissue; or
- Significant cognitive impairment (e.g., unable to participate in pre-procedure planning and/or understand discharge instructions; or
Site of care clinical review will take into consideration whether:
- The treating network participating provider recommends, based on a written clinical justification submitted to Highmark, that the service be provided at a hospital-based outpatient clinic; or
- The member requested a particular network participating provider who performs the requested service in a hospital-based outpatient clinic because the member is undergoing a continuing course of treatment with the participating provider or because the member has previously obtained the requested service from the participating provider, and the provider is not credentialed at any free-standing ambulatory surgical center in the service area and is not able to be credentialed within ninety days following the submission of the authorization request to the health care plan.

Code Descriptions

Surgical Procedures Integumentary System

15780	DERMABRASION TOTAL FACE (EG FOR ACNE SCARRING FINE WRINKLING RHYTIDS GENERAL KERATOSIS)
15782	DERMABRASION REGIONAL OTHER THAN FACE
15783	DERMABRASION SUPERFICIAL ANY SITE (EG TATTOO REMOVAL)
15786	ABRASION SINGLE LESION (EG KERATOSIS SCAR)
15788	CHEMICAL PEEL FACIAL EPIDERMAL
15789	CHEMICAL PEEL FACIAL DERMAL
15792	CHEMICAL PEEL NON-FACIAL EPIDERMAL
15793	CHEMICAL PEEL NON-FACIAL DERMAL
15820	BLEPHAROPLASTY LOWER EYELID
15821	BLEPHAROPLASTY LOWER EYELID WITH EXTENSIVE HERNIATED FAT PAD
15822	BLEPHAROPLASTY UPPER EYELID
15823	BLEPHAROPLASTY UPPER EYELID WITH EXTENSIVE SKIN WEIGHTING DOWN LID
15830	EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY) ABDOMEN INFRAUMBILICAL PANNICULECTOMY
15839	EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY) OTHER AREAS
15847	EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY) ABDOMEN (EG ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15877	SUCTION ASSISTED LIPECTOMY TRUNK
15878	SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY
15879	SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY
17106	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) LESS THAN 10 SQ CM
17107	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) 10.0- 50 SQ CM
17108	DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG LASER TECHNIQUE) OVER 50 SQ CM
17999	UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE
19318	BREAST REDUCTION

Surgical Procedures on the Musculoskeletal System

20912	CARTILAGE GRAFT NASAL SEPTUM
21089	UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE
21110	APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION INCLUDES REMOVAL
22899	UNLISTED PROCEDURE SPINE
27599	UNLISTED PROCEDURE FEMUR OR KNEE
28110	OSTECTOMY PARTIAL EXCISION FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)
28291	HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT WITH IMPLANT
28295	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH PROXIMAL METATARSAL OSTEOTOMY ANY METHOD
28296	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH DISTAL METATARSAL OSTEOTOMY ANY METHOD
28297	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS ANY METHOD
28299	CORRECTION HALLUX VALGUS WITH BUNIONECTOMY WITH SESAMOIDECTOMY WHEN PERFORMED WITH DOUBLE OSTEOTOMY ANY METHOD
28306	OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION METATARSAL FIRST METATARSAL
28322	REPAIR NONUNION OR MALUNION METATARSAL WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)
28755	ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT
29892	ARTHROSCOPICALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS DISSECANS LESION TALAR DOME FRACTURE OR TIBIAL PLAFOND FRACTURE WITH OR WITHOUT INTERNAL FIXATION (INCLUDES ARTHROSCOPY)
29899	ARTHROSCOPY ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS) SURGICAL WITH ANKLE ARTHRODESIS
29999	UNLISTED PROCEDURE ARTHROSCOPY

Surgical Procedures on the Respiratory System

30130	EXCISION INFERIOR TURBINATE PARTIAL OR COMPLETE ANY METHOD
30420	RHINOPLASTY PRIMARY INCLUDING MAJOR SEPTAL REPAIR
30435	RHINOPLASTY SECONDARY INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES)
30520	SEPTOPLASTY OR SUBMUCOUS RESECTION WITH OR WITHOUT CARTILAGE SCORING CONTOURING OR REPLACEMENT WITH GRAFT
30630	REPAIR NASAL SEPTAL PERFORATIONS
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)
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
31295	NASAL/SINUS ENDOSCOPY SURGICAL WITH DILATION (EG BALLOON DILATION) MAXILLARY SINUS OSTIUM TRANSNASAL OR VIA CANINE FOSSA

Surgical Procedures on the Cardiovascular System

33285	INSERTION SUBCUTANEOUS CARDIAC RHYTHM MONITOR INCLUDING PROGRAMMING
36465	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING SINGLE INCOMPETENT EXTREMITY TRUNCAL VEIN (EG GREAT SAPHENOUS VEIN ACCESSORY SAPHENOUS VEIN)
36466	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING MULTIPLE INCOMPETENT TRUNCAL VEINS (EG GREAT SAPHENOUS VEIN ACCESSORY SAPHENOUS VEIN) SAME LEG
36470	INJECTION OF SCLEROSANT SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA)
36471	INJECTION OF SCLEROSANT MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA) SAME LEG
36473	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS MECHANOCHEMICAL FIRST VEIN TREATED
36475	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS RADIOFREQUENCY FIRST VEIN TREATED
36476	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS RADIOFREQUENCY SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
36478	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS LASER FIRST VEIN TREATED
36479	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS LASER SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)’
36482	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS FIRST VEIN TREATED
36483	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN EXTREMITY BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING PERCUTANEOUS SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37221	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS ILIAC ARTERY UNILATERAL INITIAL VESSEL WITH TRANSLUMINAL STENT PLACEMENT(S) INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL WHEN PERFORMED
37224	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS FEMORAL POPLITEAL ARTERY(S) UNILATERAL WITH TRANSLUMINAL ANGIOPLASTY
37225	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS FEMORAL POPLITEAL ARTERY(S) UNILATERAL WITH ATHERECTOMY INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL WHEN PERFORMED
37226	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS FEMORAL POPLITEAL ARTERY(S) UNILATERAL WITH TRANSLUMINAL STENT PLACEMENT(S) INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL WHEN PERFORMED
37227	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS FEMORAL POPLITEAL ARTERY(S) UNILATERAL WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL WHEN PERFORMED
37228	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS TIBIAL PERONEAL ARTERY UNILATERAL INITIAL VESSEL WITH TRANSLUMINAL ANGIOPLASTY
37229	REVASCULARIZATION ENDOVASCULAR OPEN OR PERCUTANEOUS TIBIAL PERONEAL ARTERY UNILATERAL INITIAL VESSEL WITH ATHERECTOMY INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL WHEN PERFORMED
37243	VASCULAR EMBOLIZATION OR OCCLUSION INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION INTRAPROCEDURAL ROAD MAPPING AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION FOR TUMORS ORGAN ISCHEMIA OR INFARCTION
37700	LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION OR DISTAL INTERRUPTIONS
37761	LIGATION OF PERFORATOR VEIN(S) SUBFASCIAL OPEN INCLUDING ULTRASOUND GUIDANCE WHEN PERFORMED 1 LEG
37765	STAB PHLEBECTOMY OF VARICOSE VEINS 1 EXTREMITY 10-20 STAB INCISIONS
37766	STAB PHLEBECTOMY OF VARICOSE VEINS ONE EXTREMITY MORE THAN 20 INCISIONS
37799	UNLISTED PROCEDURE VASCULAR SURGERY

Surgical Procedures on the Digestive System

42821	TONSILLECTOMY AND ADENOIDECTOMY AGE 12 OR OVER
42826	TONSILLECTOMY PRIMARY OR SECONDARY AGE 12 OR OVER
42831	ADENOIDECTOMY PRIMARY AGE 12 OR OVER
43774	LAPAROSCOPY SURGICAL GASTRIC RESTRICTIVE PROCEDURE REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS
43775	LAPAROSCOPY SURGICAL GASTRIC RESTRICTIVE PROCEDURE LONGITUDINAL GASTRECTOMY (IE SLEEVE GASTRECTOMY)

Surgical Procedures on the Urinary System

55899

UNLISTED PROCEDURE MALE GENITAL SYSTEM

Surgical Procedures on the Nervous System

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
64561	PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE IF PERFORMED
64582	OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY PULSE GENERATOR AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY
64590	INSERTION OR REPLACEMENT OF PERIPHERAL SACRAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
64636	DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVE(S) WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT) LUMBAR OR SACRAL EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Surgical Procedures on the Eye and Ocular Adnexa

66989	EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1STAGE PROCEDURE) MANUAL OR MECHANICAL TECHNIQUE (EG IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) COMPLEX REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG IRIS EXPANSION DEVICE SUTURE SUPPORT FOR INTRAOCULAR LENS OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE WITH INSERTION OF INTRAOCULAR (EG TRABECULAR MESHWORK SUPRACILIARY SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE WITHOUT EXTRAOCULAR RESERVOIR INTERNAL APPROACH ONE OR MORE
66991	EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE) MANUAL OR MECHANICAL TECHNIQUE (EG IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) WITH INSERTION OF INTRAOCULAR (EG TRABECULAR MESHWORK SUPRACILIARY SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE WITHOUT EXTRAOCULAR RESERVOIR INTERNAL APPROACH ONE OR MORE
67900	REPAIR OF BROW PTOSIS (SUPRACILIARY MIDFOREHEAD OR CORONAL APPROACH)
67901	REPAIR OF BLEPHAROPTOSIS FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG BANKED FASCIA)
67902	REPAIR OF BLEPHAROPTOSIS FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67903	REPAIR OF BLEPHAROPTOSIS (TARSO) LEVATOR RESECTION OR ADVANCEMENT INTERNAL APPROACH
67904	REPAIR OF BLEPHAROPTOSIS (TARSO) LEVATOR RESECTION OR ADVANCEMENT EXTERNAL APPROACH
67908	REPAIR OF BLEPHAROPTOSIS CONJUNCTIVO-TARSO-MULLER S MUSCLE-LEVATOR RESECTION (EG FASANELLA-SERVAT TYPE)
67911	CORRECTION OF LID RETRACTION
67999	UNLISTED PROCEDURE EYELIDS
68899	UNLISTED PROCEDURE LACRIMAL SYSTEM

Assorted Devices, Implants, and Systems

C1820	GENERATOR NEUROSTIMULATOR (IMPLANTABLE) NON-HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM
C1822	GENERATOR NEUROSTIMULATOR (IMPLANTABLE) HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM

15780	15782	15783	15786	15788	15789	15792
15793	15820	15821	15822	15823	15830	15839
15847	15877	15878	15879	17106	17107	17108
17999	19318	20912	21089	21110	22899	27599
28110	28291	28295	28296	28297	28299	28306
28322	28755	29892	29899	29999	30130	30420
30435	30520	30630	31253	31254	31255	31257
31259	31295	33285	36465	36466	36470	36471
36473	36475	36476	36478	36479	36482	36483
37221	37224	37225	37226	37227	37228	37229
37243	37700	37761	37765	37766	37799	42821
42826	42831	43774	43775	55899	63663	63664
64561	64582	64590	66989	66991	67900	67901
67902	67903	67904	67908	67911	67999	68899
C1820	C1822

Related Policies

Refer to Medical Policy I-151, Site of Care, for additional information.

Refer to Medical Policy S-278, Blepharoplasty, Repair of Blepharoptosis, and Repair of Brow Ptosis, for additional information.

Refer to Medical Policy S-28, Cosmetic vs Reconstructive Surgery, for additional information.

Refer to Medical Policy M-77, Upper Gastrointestinal Endoscopy/Esophagoscopy, for additional information.

Refer to Medical Policy S-184, Gender Affirmation Treatment, for additional information.

Refer to Medical Policy S-201, Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents for additional information.

Refer to Medical Policy S-284, Ankle Arthroscopy, for additional information.

Refer to Medical Policy S-337, Arthrodesis, Interphalangeal Joint, for additional information.

Refer to Medical Policy, Shoulder Arthroplasty (Total, Hemi, Reverse)/Arthrodesis, for additional information.

Refer to Medical Policy S-255, Lumbar Fusion (Arthrodesis) for additional information.

Refer to Medical Policy S-324, Spinal Fusion, Thoracic and Thoracolumbar, for additional information. Refer to Medical Policy S-36, Treatment of Benign or Premalignant Skin Conditions for additional information.

Refer to Medical Policy S-280, Surgical Treatment of Obstructive Sleep Apnea, for additional information.

Refer to Medical Policy S-55, Surgical Treatment of Varicose Veins, for additional information.

Refer to Medical Policy S-552, Sclerotherapy (Liquid or Microfoam), for additional information.

Refer to Medical Policy, S-258, Spinal Cord and Implantable Peripheral Nerve Stimulators, for additional information.

Refer to Medical Policy S-385, Spinal Cord and Dorsal Root Ganglion Stimulation, for additional information.

Refer to Medical Policy S-285, Spinal Cord and Dorsal Root Ganglion Stimulation, for additional information.

Refer to Medical Policy S-40, Implantable Intrathecal Drug Delivery Systems, for additional information.

Refer to Medical Policy S-331, Bariatric Surgery, for additional information.

Refer to Medical Policy R-15, Selective Internal Radiation Therapy (SIRT)/Radioembolization, for additional information.

Refer to Medical Policy S189, Epidural Steroid Injections, for additional information.

Refer to Medical Policy S-97, Treatment of the Prostate, for additional information.

Refer to Medical Policy S-275, Prostate Disease: Diagnosis, Staging, and Treatment, for additional information.

Refer to Medical Policy Z-61, Facet Joint Injections/Medial Branch Blocks, for additional information.

Refer to Medical Policy S-185, Knee Surgery – Arthroscopic and Open Procedure, for additional information.

Refer to Medical Policy S-150, Radiofrequency Joint Ablation-Denervation, for additional information.

Refer to Medical Policy S-131, Sacral Nerve Neuromodulation, for additional information.

Professional Statements and Societal Positions Guidelines

American Society of Anesthesiology (ASA) Physical Status (PS) Classification:

ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

Brittle diabetes: Diabetes that is difficult to control due to symptoms such as predominant hyperglycemia with recurrent ketoacidosis, predominant hypoglycemia, and mixed hyper- and hypo-glycemia.

New York Heart Association (NYHA) Functional Classification:

Class I No limitation of physical activity
Class II Slight limitation of physical activity
Class III Marked limitation of physical activity
Class IV Unable to carry on any physical activity

Obstructive sleep apnea (OSA): A sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort.

A52.74	B67.0	B67.5	C22.0	C22.2	C22.3	C22.4
C22.7	C22.8	C22.9	D01.5	D50.0	D50.1	D50.8
D51.0	D51.1	D51.2	D51.3	D51.8	D52.0	D52.1
D52.8	D53.0	D53.1	D53.2	D53.8	D55.0	D55.1
D55.21	D55.29	D55.8	D56.0	D56.1	D56.2	D56.3
D56.4	D56.5	D56.8	D57.01	D57.02	D57.03	D57.09
D57.1	D57.20	D57.211	D57.212	D57.213	D57.218	D57.3
D57.40	D57.411	D57.412	D57.413	D57.418	D57.42	D57.431
D57.432	D57.433	D57.438	D57.439	D57.44	D57.451	D57.452
D57.453	D57.458	D57.80	D57.811	D57.812	D57.813	D57.818
D58.0	D58.1	D58.2	D58.8	D59.0	D59.10	D59.11
D59.12	D59.13	D59.19	D59.2	D59.31	D59.32	D59.39
D59.4	D59.5	D59.6	D59.8	D60.0	D60.1	D60.8
D61.01	D61.09	D61.1	D61.2	D61.3	D61.810	D61.811
D61.818	D61.82	D61.89	D62	D63.0	D63.1	D63.8
D64.1	D64.2	D64.3	D64.4	D64.81	D64.89	D65
D66	D67	D68.01	D68.020	D68.021	D68.022	D68.023
D68.03	D68.04	D68.09	D68.1	D68.2	D68.311	D68.312
D68.318	D68.32	D68.4	D68.51	D68.52	D68.59	D68.61
D68.62	D68.69	D68.8	D69.0	D69.1	D69.2	D69.3
D69.41	D69.42	D69.49	D69.51	D69.59	D69.8	D69.8
D69.9	D70.0	D70.1	D70.2	D70.3	D70.4	D70.8
D71	D72.0	D72.10	D72.110	D72.111	D72.118	D72.119
D72.12	D72.18	D72.19	D72.810	D72.818	D72.820	D72.821
D72.822	D72.823	D72.824	D72.825	D72.828	D72.89	D72.9
D73.0	D73.1	D73.2	D73.3	D73.4	D73.5	D73.81
D73.89	D74.0	D74.8	D74.9	D75.0	D75.1	D75.81
D75.821	D75.822	D75.828	D75.838	D75.84	D75.89	D75.9
D75.A	D76.1	D76.2	D76.3	D77	D80.0	D80.1
D80.2	D80.3	D80.4	D80.5	D80.6	D80.7	D80.8
D81.0	D81.1	D81.2	D81.30	D81.31	D81.32	D81.39
D81.4	D81.5	D81.6	D81.7	D81.810	D81.818	D81.82
D81.89	D81.9	D82.0	D82.1	D82.2	D82.3	D82.4
D82.8	D83.0	D83.1	D83.2	D83.8	D84.0	D84.1
D84.81	D84.821	D84.822	D84.89	D86.0	D86.1	D86.2
D86.3	D86.81	D86.82	D86.83	D86.84	D86.85	D86.86
D86.87	D86.89	D89.0	D89.1	D89.3	D89.40	D89.41
D89.42	D89.43	D89.44	D89.49	D89.810	D89.811	D89.812
D89.82	D89.831	D89.832	D89.833	D89.834	D89.835	D89.89
D89.9	E08.10	E08.11	E08.649	E10.649	E10.9	E11.649
E13.649	E66.01	F01.50	F01.511	F01.518	F01.52	F01.53
F01.54	F01.A0	F01.A11	F01.A18	F01.A2	F01.A3	F01.A4
F01.B0	F01.B11	F01.B18	F01.B2	F01.B3	F01.B4	F01.C0
F01.C11	F01.C18	F01.C2	F01.C3	F01.C4	F02.80	F02.811
F02.818	F02.82	F02.83	F02.84	F02.A0	F02.A11	F02.A18
F02.A2	F02.A3	F02.A4	F02.B0	F02.B11	F02.B18	F02.B2
F02.B3	F02.B4	F02.C0	F02.C11	F02.C18	F02.C2	F02.C3
F02.C4	F03.90	F03.911	F03.918	F03.92	F03.93	F03.94
F03.A0	F03.A11	F03.A18	F03.A2	F03.A3	F03.A4	F03.B0
F03.B11	F03.B18	F03.B2	F03.B3	F03.B4	F03.C0	F03.C11
F03.C18	F03.C2	F03.C2	F03.C3	F03.C3	F03.C4	F03.C4
F04	F10.239	F10.27	F10.97	F11.10	F11.11	F12.11
F13.11	F13.27	F13.97	F14.11	F15.11	F18.17	F18.27
F18.97	F19.17	F19.27	F19.97	G30.0	G30.1	G30.8
G31.01	G31.09	G31.83	G45.0	G45.1	G45.2	G45.3
G45.4	G45.8	G45.9	G46.0	G46.1	G46.2	G47.33
I1A.0	I21.01	I21.02	I21.09	I21.11	I21.19	I21.21
I21.29	I21.3	I21.4	I25.10	I25.110	I25.111	I25.112
I25.118	I25.119	I25.2	I25.3	I25.41	I25.42	I25.5
I25.6	I25.700	I25.701	I25.702	I25.708	I25.710	I25.711
I25.712	I25.718	I25.720	I25.721	I25.722	I25.728	I25.730
I25.731	I25.732	I25.738	I25.750	I25.751	I25.752	I25.758
I25.760	I25.761	I25.762	I25.768	I25.790	I25.791	I25.792
I25.798	I25.810	I25.811	I25.812	I25.82	I25.83	I25.84
I25.89	I25.9	I34.0	I34.1	I34.2	I34.81	I34.89
I34.9	I35.0	I35.1	I35.2	I35.8	I35.9	I36.0
I36.1	I36.2	I36.8	I36.9	I37.0	I37.1	I37.2
I37.8	I37.9	I38	I39	I47.0	I47.9	I48.0
I48.11	I48.20	I48.21	I48.3	I48.4	I48.91	I48.92
I49.1	I49.2	I49.3	I49.40	I49.49	I49.5	I49.8
I50.22	I50.23	I50.32	I50.33	I50.42	I50.43	I50.812
I50.813	I63.00	I63.011	I63.012	I63.013	I63.02	I63.031
I63.032	I63.033	I63.09	I63.211	I63.212	I63.213	I63.22
I63.231	I63.232	I63.233	I63.29	I63.311	I63.312	I63.313
I63.321	I63.322	I63.323	I63.331	I63.332	I63.333	I63.341
I63.342	I63.343	I63.39	I63.511	I63.512	I63.513	I63.521
I63.522	I63.523	I63.531	I63.532	I63.533	I63.541	I63.542
I63.543	I63.59	I63.81	I63.89	I73.00	I73.01	I73.1
I73.81	I73.89	J41.0	J41.1	J41.8	J42	J43.0
J43.1	J43.2	J43.8	J44.0	J44.1	J44.9	J45.31
J45.32	J45.40	J45.41	J45.42	J45.50	J45.51	J45.52
J45.901	J45.902	J45.991	J45.998	J47.0	J47.1	J47.9
K70.0	K70.2	K70.30	K70.31	K70.9	K71.0	K71.10
K71.11	K71.7	K71.8	K71.9	K74.0	K74.00	K74.01
K74.02	K74.1	K74.2	K74.3	K74.4	K74.5	K74.60
K74.69	K75.1	K75.89	K75.9	K76.0	K76.1	K76.2
K76.3	K76.4	K76.5	K76.6	K76.7	K76.81	K76.89
K76.9	K77	M79.5	N18.5	N18.6	O09.01	O09.02
O09.03	O09.11	O09.12	O09.13	O09.211	O09.212	O09.213
O09.291	O09.292	O09.293	O09.31	O09.32	O09.33	O09.41
O09.42	O09.43	O09.511	O09.512	O09.513	O09.521	O09.522
O09.523	O09.611	O09.612	O09.613	O09.621	O09.622	O09.623
O09.71	O09.72	O09.73	O09.811	O09.812	O09.813	O09.821
O09.822	O09.823	O09.891	O09.892	O09.893	O09.A1	O09.A2
O09.A3	O10.011	O10.012	O10.013	O10.111	O10.112	O10.113
O10.211	O10.212	O10.213	O10.311	O10.312	O10.313	O10.411
O10.412	O10.413	O10.911	O10.912	O10.913	O11.1	O11.2
O11.3	O12.01	O12.02	O12.03	O12.11	O12.12	O12.13
O12.21	O12.22	O12.23	O13.1	O13.2	O13.3	O14.02
O14.03	O14.10	O14.12	O14.13	O14.22	O14.23	O14.92
O14.93	O15.02	O15.03	O15.1	O15.9	O16.1	O16.2
O16.3	O20.0	O20.8	O20.9	O21.0	O21.1	O21.2
O21.8	O21.9	O22.01	O22.02	O22.03	O22.11	O22.12
O22.13	O22.21	O22.22	O22.23	O22.31	O22.32	O22.33
O22.41	O22.42	O22.43	O22.51	O22.52	O22.53	O22.8X1
O22.8X2	O22.8X3	O23.01	O23.02	O23.03	O23.11	O23.12
O23.13	O23.21	O23.22	O23.23	O23.31	O23.32	O23.33
O23.41	O23.42	O23.43	O23.511	O23.512	O23.513	O23.521
O23.522	O23.523	O23.591	O23.592	O23.593	O23.91	O23.92
O23.93	O24.011	O24.012	O24.013	O24.111	O24.112	O24.113
O24.410	O24.414	O24.415	O24.811	O24.812	O24.813	O25.11
O25.12	O25.13	O26.01	O26.02	O26.03	O26.11	O26.12
O26.13	O26.21	O26.22	O26.23	O26.31	O26.32	O26.33
O26.41	O26.42	O26.43	O26.51	O26.52	O26.53	O26.611
O26.612	O26.613	O26.62	O26.63	O26.711	O26.712	O26.713
O26.811	O26.812	O26.813	O26.821	O26.822	O26.823	O26.831
O26.832	O26.833	O26.841	O26.842	O26.843	O26.851	O26.852
O26.853	O26.86	O26.872	O26.873	O26.891	O26.892	O26.893
O28.0	O28.1	O28.2	O28.3	O28.4	O28.5	O28.8
O28.9	O29.011	O29.012	O29.013	O29.021	O29.022	O29.023
O29.091	O29.092	O29.093	O29.111	O29.112	O29.113	O29.121
O29.122	O29.123	O29.191	O29.192	O29.193	O29.211	O29.212
O29.213	O29.291	O29.292	O29.293	O29.3X1	O29.3X2	O29.3X3
O29.41	O29.42	O29.43	O29.5X1	O29.5X2	O29.5X3	O29.61
O29.62	O29.63	O29.8X1	O29.8X2	O29.8X3	O29.91	O29.92
O29.93	O30.001	O30.002	O30.003	O30.011	O30.012	O30.013
O30.021	O30.022	O30.023	O30.031	O30.032	O30.033	O30.041
O30.042	O30.043	O30.091	O30.092	O30.093	O30.101	O30.102
O30.103	O30.111	O30.112	O30.113	O30.121	O30.122	O30.123
O30.131	O30.132	O30.133	O30.191	O30.192	O30.193	O30.201
O30.202	O30.203	O30.211	O30.212	O30.213	O30.221	O30.222
O30.223	O30.231	O30.232	O30.233	O30.291	O30.292	O30.293
O30.801	O30.802	O30.803	O30.811	O30.812	O30.813	O30.821
O30.822	O30.823	O30.831	O30.832	O30.833	O30.891	O30.892
O30.893	O30.91	O30.92	O30.93	O31.01X1	O31.01X2	O31.01X3
O31.01X4	O31.01X5	O31.01X9	O31.02X1	O31.02X2	O31.02X3	O31.02X4
O31.02X5	O31.02X9	O31.03X1	O31.03X2	O31.03X3	O31.03X4	O31.03X5
O31.03X9	O31.11X0	O31.11X1	O31.11X2	O31.11X3	O31.11X4	O31.11X5
O31.11X9	O31.12X0	O31.12X1	O31.12X2	O31.12X3	O31.12X4	O31.12X5
O31.12X9	O31.13X0	O31.13X1	O31.13X2	O31.13X3	O31.13X4	O31.13X5
O31.13X9	O31.21X0	O31.21X1	O31.21X2	O31.21X3	O31.21X4	O31.21X5
O31.21X9	O31.22X1	O31.22X2	O31.22X3	O31.22X4	O31.22X5	O31.22X9
O31.23X1	O31.23X2	O31.23X3	O31.23X4	O31.23X5	O31.23X9	O31.31X1
O31.31X2	O31.31X3	O31.31X4	O31.31X5	O31.31X9	O31.32X1	O31.32X2
O31.32X3	O31.32X4	O31.32X5	O31.32X9	O31.33X1	O31.33X2	O31.33X3
O31.33X4	O31.33X5	O31.33X9	O31.8X10	O31.8X11	O31.8X12	O31.8X13
O31.8X14	O31.8X15	O31.8X19	O31.8X20	O31.8X21	O31.8X22	O31.8X23
O31.8X24	O31.8X25	O31.8X29	O31.8X30	O31.8X31	O31.8X32	O31.8X33
O31.8X34	O31.8X35	O31.8X39	O32.0XX1	O32.0XX2	O32.0XX3	O32.0XX4
O32.0XX5	O32.1XX1	O32.1XX2	O32.1XX3	O32.1XX4	O32.1XX5	O32.1XX9
O32.2XX1	O32.2XX2	O32.2XX3	O32.2XX4	O32.2XX5	O32.2XX9	O32.3XX1
O32.3XX2	O32.3XX3	O32.3XX4	O32.3XX5	O32.3XX9	O32.4XX1	O32.4XX2
O32.4XX3	O32.4XX4	O32.4XX5	O32.4XX9	O32.6XX1	O32.6XX2	O32.6XX3
O32.6XX4	O32.6XX5	O32.6XX9	O32.8XX1	O32.8XX2	O32.8XX3	O32.8XX4
O32.8XX5	O32.8XX9	O33.0	O33.1	O33.2	O33.3XX1	O33.3XX2
O33.3XX3	O33.3XX4	O33.3XX5	O33.3XX9	O33.4XX1	O33.4XX2	O33.4XX3
O33.4XX4	O33.4XX5	O33.4XX9	O33.5XX1	O33.5XX2	O33.5XX3	O33.5XX4
O33.5XX5	O33.5XX9	O33.6XX1	O33.6XX2	O33.6XX3	O33.6XX4	O33.6XX5
O33.6XX9	O33.7	O33.7XX1	O33.7XX2	O33.7XX3	O33.7XX4	O33.7XX5
O33.7XX9	O33.8	O33.9	O34.01	O34.02	O34.03	O34.10
O34.11	O34.12	O34.13	O34.21	O34.211	O34.212	O34.218
O34.219	O34.22	O34.29	O34.31	O34.32	O34.33	O34.41
O34.42	O34.43	O34.511	O34.512	O34.513	O34.521	O34.522
O34.523	O34.531	O34.532	O34.533	O34.591	O34.592	O34.593
O34.61	O34.62	O34.63	O34.71	O34.72	O34.73	O34.81
O34.82	O34.83	O34.91	O34.92	O34.93	O35.0XX1	O35.0XX2
O35.0XX3	O35.0XX4	O35.0XX5	O35.0XX9	O35.1XX1	O35.1XX2	O35.1XX3
O35.1XX4	O35.1XX5	O35.1XX9	O35.2XX1	O35.2XX2	O35.2XX3	O35.2XX4
O35.2XX5	O35.2XX9	O35.3XX1	O35.3XX2	O35.3XX3	O35.3XX4	O35.3XX5
O35.3XX9	O35.4XX1	O35.4XX2	O35.4XX3	O35.4XX4	O35.4XX5	O35.4XX9
O35.5XX1	O35.5XX2	O35.5XX3	O35.5XX4	O35.5XX5	O35.5XX9	O35.6XX1
O35.6XX2	O35.6XX3	O35.6XX4	O35.6XX5	O35.6XX9	O35.7XX1	O35.7XX2
O35.7XX3	O35.7XX4	O35.7XX5	O35.7XX9	O35.8XX1	O35.8XX2	O35.8XX3
O35.8XX4	O35.8XX5	O35.8XX9	O36.0111	O36.0112	O36.0113	O36.0114
O36.0115	O36.0119	O36.0121	O36.0122	O36.0123	O36.0124	O36.0125
O36.0129	O36.0131	O36.0132	O36.0133	O36.0134	O36.0135	O36.0139
O36.0911	O36.0912	O36.0913	O36.0914	O36.0915	O36.0919	O36.0921
O36.0922	O36.0923	O36.0924	O36.0925	O36.0929	O36.0931	O36.0932
O36.0933	O36.0934	O36.0935	O36.0939	O36.1111	O36.1112	O36.1113
O36.1114	O36.1115	O36.1119	O36.1121	O36.1122	O36.1123	O36.1124
O36.1125	O36.1129	O36.1131	O36.1132	O36.1133	O36.1134	O36.1135
O36.1139	O36.1911	O36.1912	O36.1913	O36.1914	O36.1915	O36.1919
O36.1921	O36.1922	O36.1923	O36.1924	O36.1925	O36.1929	O36.1931
O36.1932	O36.1933	O36.1934	O36.1935	O36.1939	O36.21X1	O36.21X2
O36.21X3	O36.21X4	O36.21X5	O36.21X9	O36.22X1	O36.22X2	O36.22X3
O36.22X4	O36.22X5	O36.22X9	O36.23X1	O36.23X2	O36.23X3	O36.23X4
O36.23X5	O36.23X9	O36.4XX1	O36.4XX2	O36.4XX3	O36.4XX4	O36.4XX5
O36.4XX9	O36.5111	O36.5112	O36.5113	O36.5114	O36.5115	O36.5119
O36.5121	O36.5122	O36.5123	O36.5124	O36.5125	O36.5129	O36.5131
O36.5132	O36.5133	O36.5134	O36.5135	O36.5139	O36.5911	O36.5912
O36.5913	O36.5914	O36.5915	O36.5919	O36.5921	O36.5922	O36.5923
O36.5924	O36.5925	O36.5929	O36.5931	O36.5932	O36.5933	O36.5934
O36.5935	O36.5939	O36.61X1	O36.61X2	O36.61X3	O36.61X4	O36.61X5
O36.61X9	O36.62X1	O36.62X2	O36.62X3	O36.62X4	O36.62X5	O36.62X9
O36.63X1	O36.63X2	O36.63X3	O36.63X4	O36.63X5	O36.63X9	O36.71X1
O36.71X2	O36.71X3	O36.71X4	O36.71X5	O36.71X9	O36.72X1	O36.72X2
O36.72X3	O36.72X4	O36.72X5	O36.72X9	O36.73X1	O36.73X2	O36.73X3
O36.73X4	O36.73X5	O36.73X9	O36.80X1	O36.80X2	O36.80X3	O36.80X4
O36.80X5	O36.80X9	O36.8121	O36.8122	O36.8123	O36.8124	O36.8125
O36.8129	O36.8131	O36.8132	O36.8133	O36.8134	O36.8135	O36.8139
O36.8211	O36.8212	O36.8213	O36.8214	O36.8215	O36.8219	O36.8221
O36.8222	O36.8223	O36.8224	O36.8225	O36.8229	O36.8231	O36.8232
O36.8233	O36.8234	O36.8235	O36.8239	O36.8311	O36.8312	O36.8313
O36.8314	O36.8315	O36.8319	O36.8321	O36.8322	O36.8323	O36.8324
O36.8325	O36.8329	O36.8331	O36.8332	O36.8333	O36.8334	O36.8335
O36.8339	O36.8911	O36.8912	O36.8913	O36.8914	O36.8915	O36.8919
O36.8921	O36.8922	O36.8923	O36.8924	O36.8925	O36.8929	O36.8931
O36.8932	O36.8933	O36.8934	O36.8935	O36.8939	O40.1XX1	O40.1XX2
O40.1XX3	O40.1XX4	O40.1XX5	O40.1XX9	O40.2XX1	O40.2XX2	O40.2XX3
O40.2XX4	O40.2XX5	O40.2XX9	O40.3XX1	O40.3XX2	O40.3XX3	O40.3XX4
O40.3XX5	O40.3XX9	O41.01X1	O41.01X2	O41.01X3	O41.01X4	O41.01X5
O41.01X9	O41.02X1	O41.02X2	O41.02X3	O41.02X4	O41.02X5	O41.02X9
O41.03X1	O41.03X2	O41.03X3	O41.03X4	O41.03X5	O41.03X9	O41.1010
O41.1011	O41.1012	O41.1013	O41.1014	O41.1015	O41.1019	O41.1020
O41.1021	O41.1022	O41.1023	O41.1024	O41.1025	O41.1029	O41.1031
O41.1032	O41.1033	O41.1034	O41.1035	O41.1039	O41.1211	O41.1212
O41.1213	O41.1214	O41.1215	O41.1219	O41.1221	O41.1222	O41.1223
O41.1224	O41.1225	O41.1229	O41.1231	O41.1232	O41.1233	O41.1234
O41.1235	O41.1239	O41.1411	O41.1412	O41.1413	O41.1414	O41.1415
O41.1419	O41.1421	O41.1422	O41.1423	O41.1424	O41.1425	O41.1429
O41.1431	O41.1432	O41.1433	O41.1434	O41.1435	O41.1439	O41.8X11
O41.8X12	O41.8X13	O41.8X14	O41.8X15	O41.8X19	O41.8X21	O41.8X22
O41.8X23	O41.8X24	O41.8X25	O41.8X29	O41.8X31	O41.8X32	O41.8X33
O41.8X34	O41.8X35	O41.8X39	O41.91X0	O41.91X1	O41.91X2	O41.91X3
O41.91X4	O41.91X5	O41.91X9	O41.92X0	O41.92X1	O41.92X2	O41.92X3
O41.92X4	O41.92X5	O41.92X9	O41.93X0	O41.93X1	O41.93X2	O41.93X3
O41.93X4	O41.93X5	O41.93X9	O42.00	O42.011	O42.012	O42.013
O42.02	O42.10	O42.111	O42.112	O42.113	O42.12	O42.90
O42.911	O42.912	O42.913	O42.92	O43.011	O43.012	O43.013
O43.021	O43.022	O43.023	O43.101	O43.102	O43.103	O43.111
O43.112	O43.113	O43.121	O43.122	O43.123	O43.191	O43.192
O43.193	O43.211	O43.212	O43.213	O43.221	O43.222	O43.223
O43.231	O43.232	O43.233	O43.811	O43.812	O43.813	O43.891
O43.892	O43.893	O43.91	O43.92	O43.93	O44.01	O44.02
O44.03	O44.11	O44.12	O44.13	O44.21	O44.22	O44.23
O44.31	O44.32	O44.33	O44.41	O44.42	O44.43	O44.51
O44.52	O44.53	O45.001	O45.002	O45.003	O45.011	O45.012
O45.013	O45.021	O45.022	O45.023	O45.091	O45.092	O45.093
O45.8X1	O45.8X2	O45.8X3	O46.001	O46.002	O46.003	O46.011
O46.012	O46.013	O46.021	O46.022	O46.023	O46.091	O46.092
O46.093	O46.8X1	O46.8X2	O46.8X3	O46.91	O46.92	O46.93
O47.00	O47.02	O47.03	O47.1	O47.9	O48.0	O48.1
O60.02	O60.03	O71.00	O71.02	O71.03	O71.1	O71.2
O71.3	O71.4	O71.5	O71.6	O71.7	O71.81	O71.82
O71.89	O71.9	O88.011	O88.012	O88.013	O88.111	O88.112
O88.113	O88.211	O88.212	O88.213	O88.311	O88.312	O88.313
O88.811	O88.812	O88.813	O91.011	O91.012	O91.013	O91.03
O91.111	O91.112	O91.113	O91.13	O91.211	O91.212	O91.213
O91.23	O92.011	O92.012	O92.013	O92.03	O92.111	O92.112
O92.113	O92.13	O92.3	O92.4	O92.5	O92.6	O92.79
O98.011	O98.012	O98.013	O98.111	O98.112	O98.113	O98.211
O98.212	O98.213	O98.311	O98.312	O98.313	O98.411	O98.412
O98.413	O98.511	O98.512	O98.513	O98.611	O98.612	O98.613
O98.711	O98.712	O98.713	O98.811	O98.812	O98.813	O98.911
O98.912	O98.913	O99.011	O99.012	O99.013	O99.111	O99.112
O99.113	O99.211	O99.212	O99.213	O99.281	O99.282	O99.283
O99.311	O99.312	O99.313	O99.321	O99.322	O99.323	O99.331
O99.332	O99.333	O99.341	O99.342	O99.343	O99.351	O99.352
O99.353	O99.411	O99.412	O99.413	O99.511	O99.512	O99.513
O99.611	O99.612	O99.613	O99.711	O99.712	O99.713	O99.810
O99.820	O99.830	O99.841	O99.842	O99.843	O99.891	O9A.111
O9A.112	O9A.113	O9A.211	O9A.212	O9A.213	O9A.311	O9A.312
O9A.313	O9A.411	O9A.412	O9A.413	O9A.511	O9A.512	O9A.513
T15.01XA	T15.01XD	T15.01XS	T15.02XA	T15.02XD	T15.02XS	T15.11XA
T15.11XD	T15.11XS	T15.12XA	T15.12XD	T15.12XS	T15.81XA	T15.81XD
T15.81XS	T15.82XA	T15.82XD	T15.82XS	T15.91XA	T15.91XD	T15.91XS
T15.92XA	T15.92XD	T15.92XS	T16.1XXA	T16.1XXD	T16.1XXS	T16.2XXA
T16.2XXD	T16.2XXS	T17.0XXA	T17.0XXD	T17.0XXS	T17.1XXA	T17.1XXD
T17.1XXS	T17.200A	T17.200D	T17.200S	T17.208A	T17.208D	T17.208S
T17.210A	T17.210D	T17.210S	T17.218A	T17.218D	T17.218S	T17.220A
T17.220D	T17.220S	T17.228A	T17.228D	T17.228S	T17.290A	T17.290D
T17.290S	T17.298A	T17.298D	T17.298S	T17.300A	T17.300D	T17.300S
T17.308A	T17.308D	T17.308S	T17.310A	T17.310D	T17.310S	T17.318A
T17.318D	T17.318S	T17.320A	T17.320D	T17.320S	T17.328A	T17.328D
T17.328S	T17.390A	T17.390D	T17.390S	T17.398A	T17.398D	T17.398S
T17.400A	T17.400D	T17.400S	T17.408A	T17.408D	T17.408S	T17.410A
T17.410D	T17.410S	T17.418A	T17.418D	T17.418S	T17.420A	T17.420D
T17.420S	T17.428A	T17.428D	T17.428S	T17.490A	T17.490D	T17.490S
T17.498A	T17.498D	T17.498S	T17.500A	T17.500D	T17.500S	T17.508A
T17.508D	T17.508S	T17.510A	T17.510D	T17.510S	T17.518A	T17.518D
T17.518S	T17.520A	T17.520D	T17.520S	T17.528A	T17.528D	T17.528S
T17.590A	T17.590D	T17.590S	T17.598A	T17.598D	T17.598S	T17.800A
T17.800D	T17.800S	T17.808A	T17.808D	T17.808S	T17.810A	T17.810D
T17.810S	T17.818A	T17.818D	T17.818S	T17.820A	T17.820D	T17.820S
T17.828A	T17.828D	T17.828S	T17.890A	T17.890D	T17.890S	T17.898A
T17.898D	T17.898S	T17.900A	T17.900D	T17.900S	T17.908A	T17.908D
T17.908S	T17.910A	T17.910D	T17.910S	T17.918A	T17.918D	T17.918S
T17.920A	T17.920D	T17.920S	T17.928A	T17.928D	T17.928S	T17.990A
T17.990D	T17.990S	T17.998A	T17.998D	T17.998S	T18.0XXA	T18.0XXD
T18.0XXS	T18.100A	T18.100D	T18.100S	T18.108A	T18.108D	T18.108S
T18.110A	T18.110D	T18.110S	T18.118A	T18.118D	T18.118S	T18.120A
T18.120D	T18.120S	T18.128A	T18.128D	T18.128S	T18.190A	T18.190D
T18.190S	T18.198A	T18.198D	T18.198S	T18.2XXA	T18.2XXD	T18.2XXS
T18.3XXA	T18.3XXD	T18.3XXS	T18.4XXA	T18.4XXD	T18.4XXS	T18.5XXA
T18.5XXD	T18.5XXS	T18.8XXA	T18.8XXD	T18.8XXS	T18.9XXA	T18.9XXD
T18.9XXS	T19.0XXA	T19.0XXD	T19.0XXS	T19.1XXA	T19.1XXD	T19.1XXS
T19.2XXA	T19.2XXD	T19.2XXS	T19.3XXA	T19.3XXD	T19.3XXS	T19.4XXA
T19.4XXD	T19.4XXS	T19.8XXA	T19.8XXD	T19.8XXS	T19.9XXA	T19.9XXD
T19.9XXS	T88.4XXA	T88.4XXD	T88.4XXS	T88.59XA	T88.59XD	T88.59XS
Z00.111	Z00.121	Z00.129	Z01.83	Z03.71	Z03.72	Z03.73
Z03.74	Z03.75	Z03.79	Z13.0	Z13.6	Z18.89	Z18.9
Z32.01	Z34.01	Z34.02	Z34.03	Z34.81	Z34.82	Z34.83
Z36.0	Z36.1	Z36.2	Z36.3	Z36.4	Z36.5	Z36.81
Z36.82	Z36.83	Z36.84	Z36.85	Z36.86	Z36.87	Z36.88
Z36.89	Z36.8A	Z53.09	Z74.09	Z86.73	Z86.74	Z91.89
Z92.83	Z92.84	Z95.5	Z95.810	Z95.811	Z95.818	Z95.820
Z95.828	Z95.9	Z98.61	Z99.11	Z99.12	Z99.2	Z99.2
Z99.81

Place of Service: Inpatient/Outpatient

Site of care is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Evidence-based guidelines support the choice of site of care.

The policy position applies to all commercial lines of business

Links

Link to Provider Resource Center for the Medical Policy Update

4/2025, New Policy Z-109 Established for Site of Care

Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

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 the Claims Administrator/Insurer 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, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. 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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

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 the Claims Administrator/Insurer 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, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. 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.