This policy version was replaced on August 2, 2021. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

NOTE: The intent of this policy is to provide clinical criteria for use of an outpatient hospital setting for selected outpatient procedures. Many specialists in the Blue Cross network have already started redirecting patients to ambulatory surgery centers (ASCs) for these procedures when clinically appropriate. Groups performing these procedures outside the hospital have shown evidence of safe, high quality outcomes, while maintaining an excellent patient experience.

This policy addresses patient and/or procedural factors that may increase a patient’s risk of requiring urgent access to a higher level of care available in a hospital outpatient facility rather than an ASC during outpatient procedures, including but not limited to endoscopic procedures.

Definitions

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.

Site of service: The location where the outpatient procedure is performed, including the following:

• Off Campus-Outpatient Hospital (Code 19): 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.
• Hospital Inpatient (Code 21): 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.
• On Campus-Outpatient Hospital (Code 22): A portion of a hospital’s 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.
• Ambulatory Surgical Center (Code 24): A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

NOTE:

• This policy applies to commercial health plan members and Minnesota Health Care Program subscribers to Families and Children and MinnesotaCare.
• See table below for outpatient procedures included in the ambulatory surgery center (ASC) site of service program.

Outpatient Hospital Site of Service

I.    When the criteria in Section II are not met, use of a hospital outpatient facility for an outpatient procedure is considered NOT MEDICALLY NECESSARY and a non-hospital outpatient setting (e.g., ambulatory surgery center, office-based surgical suite) should be used.

II.     Use of a hospital outpatient facility for an outpatient procedure, may be considered MEDICALLY NECESSARY AND APPROPRIATE when any of the following criteria are met:

• Age <18 years;
• Nearest in-network non-hospital outpatient facility with procedural capabilities is >25 miles from patient’s home;
• Planned length of stay >24 hours;
• Anesthesia risk
  • American Society of Anesthesiologists (ASA) Physical Status (PS) Classification IV or higher (see definition);
  • History of complications from anesthesia (e.g., malignant hyperthermia);
  • Alcohol dependence at risk for withdrawal syndrome;
  • Recent history of drug abuse (e.g., cocaine) (<3 months);
  • Prolonged surgery (>3 hours);
  • Known or suspected difficult airway;
• Increased cardiovascular risk, including but not limited to:
  • Uncompensated chronic heart failure (NYHA class III or IV) (see definition);
  • Recent history of myocardial infarction (MI) (<6 months);
  • Poorly controlled, resistant hypertension;
  • Recent history of cerebrovascular accident or transient ischemic attack (<3 months);
  • Increased risk for cardiac ischemia (cardiac or vascular stent placed <1 year or angioplasty <90 days);
  • Cardiac arrhythmia that increases periprocedural or anesthesia risk;
  • Moderate or severe valvular heart disease;
  • Implantable cardioverter-defibrillator (ICD);
  • Mechanical cardiovascular support (e.g., left ventricular assist device [LVAD] or total artificial heart);
• 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);
  • Moderate or severe persistent asthma (FEV1 <80% despite treatment);
  • Moderate to severe obstructive sleep apnea (OSA) (AHI or RDI ≥15);
  • Dependent on a ventilator;
  • Dependent on continuous supplemental oxygen;
• Increased liver risk, including but not limited to:
  • Advanced liver disease (MELD Score >8);
• Increased renal risk, including but not limited to:
  • End stage renal disease on dialysis;
• Increased bleeding risk, including but not limited to:
  • Bleeding disorder requiring replacement factor, blood products, DDAVP/desmopressin, or special infusion product; 
  • Anticipated need for transfusion(s);
    
• Other
  • Morbid obesity (BMI ≥40);
  • Brittle diabetes or HbA1C ≥ 8.5%;
  • Pregnancy;
  • Cannot transfer independently;
  • Known or suspected foreign body in the target organ or tissue;
  • Significant cognitive impairment (e.g., unable to participate in pre-procedure planning and/or understand discharge instructions).

Inpatient Hospital Site of Service 

III.   Use of an inpatient hospital facility solely for a procedure noted in the table below is considered NOT MEDICALLY NECESSARY.

Table. Outpatient Procedures Included in the Site of Service Program