March 1, 2018
To encourage the use of the most safe, appropriate, and cost-effective sites of service for certain medically necessary outpatient surgical procedures, prior authorization will include review for the site of service when requesting select elective surgical procedures starting June 1, 2018.
Site of service is defined as the location where the surgical procedure is performed. The preferred site of service is the outpatient setting, such as an off campus-outpatient hospital/medical center or an ambulatory surgical center for select elective procedures related to:
- Breast
- Ear/nose/throat
- Heart
- Knee
- Spine
When an elective surgery is requested at an inpatient hospital/medical center, this site may be considered medically necessary only when the patient has a clinical conditions that places him or her at risk of complications. Examples include:
- Anesthesia risk
- Cardiovascular, liver, pulmonary, or renal risk
- Morbid obesity
- Pregnancy
- Bleeding disorder
- Anticipated need for transfusions
To review all of the site-of-service criteria for the affected services, please see policy 11.01.524 Site of Service: Select Surgical Procedures.