UTILIZATION MANAGEMENT GUIDELINE – 11.01.524 Site of Service: Select Surgical Procedures Effective Date: Feb. 5. 2021 RELATED MEDICAL POLICIES: Last Revised: May 27, 2021 2.02.507 Coronary Angiography Replaces: N/A 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 Lesions 7.01.101 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 7.01.108 Artificial Intervertebral Disc: Cervical Spine 7.01.503 Reduction Mammaplasty for Breast-related Symptoms 7.01.533 Reconstructive Breast Surgery/Management of Breast Implants 7.01.549 Knee Arthroscopy in Adults 7.01.546 Spinal Cord and Dorsal Ganglion Root Stimulation 7.01.551 Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy 7.01.558 Rhinoplasty 7.01.559 Sinus Surgery Select a hyperlink below to be directed to that section. COVERAGE GUIDELINES | CODING | RELATED INFORMATION | REFERENCES | HISTORY ∞ Clicking this icon returns you to the hyperlinks menu above. 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 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 Medical Necessity Elective Surgical Procedures Medically necessary sites Certain elective surgical procedures will be covered in the most of service: appropriate, safe, and cost effective site. These are the • Off campus-outpatient preferred medically necessary sites of service for certain hospital/medical center elective surgical procedures. • On campus-outpatient hospital/medical center • Ambulatory surgical center Inpatient hospital/medical Certain elective surgical procedures will be covered in the most center 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) (<3 months) o Poorly controlled, resistant hypertension* o Recent history of cerebrovascular accident (< 3 months) Page | 2 of 16 ∞ Site of Service for Medical Necessity Elective Surgical Procedures o Increased risk for cardiac ischemia (drug eluting stent placed < 1 year or angioplasty <90 days) o Symptomatic cardiac arrhythmia despite medication o Significant valvular heart disease • Liver Risk o Advanced liver disease (MELD Score > 8)** • Pulmonary Risk o Chronic obstructive pulmonary disease (COPD) (FEV1 <50%) o Poorly controlled asthma (FEV1 <80% despite treatment) o Moderate to severe obstructive sleep apnea (OSA)*** • Renal Risk o End stage renal disease (on dialysis) • Other o Morbid obesity (BMI ≥ 50) o Pregnancy o Bleeding disorder (requiring replacement factor, blood products, or special infusion product [DDAVP**** does not meet this criteria]) o Anticipated need for transfusion(s) Note: * 3 or more drugs to control blood pressure ** https://reference.medscape.com/calculator/meld-score-end- stage-liver-disease *** Moderate-AHI≥15 and ≤ 30, Severe-AHI ≥30 ****DDAVP-Deamino-Delta-D-Arginine Vasopressin (Desmopressin) Inpatient hospital/medical This site of service is considered NOT medically necessary for center certain elective surgical procedures when the site of service criteria listed above in this policy are not met. Page | 3 of 16 ∞ 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 KNEE SURGERY EAR, NOSE, THROAT (ENT) SURGERY SPINE SURGERY HEART SURGERIES 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 7.01.558 • Primary rhinoplasty and/or elevation of nasal tip • Primary rhinoplasty; complete (external parts including bony pyramid) • Primary rhinoplasty; including major septal repair • Secondary rhinoplasty; minor revision (small amount of nasal tip work) o Secondary rhinoplasty; intermediate revision (bony work with osteotomies) . Secondary rhinoplasty; major revision (nasal tip work and osteotomies) Sinus Surgery 7.01.559 • Nasal/sinus endoscopy with partial, anterior, ethmoidectomy o Nasal/sinus endoscopy with total, anterior/posterior, ethmoidectomy . Nasal/sinus endoscopy with 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 Page | 4 of 16 ∞ Ear, Nose, Throat (ENT) Surgeries o Nasal/sinus endoscopy with maxillary antrostomy with removal of tissue from maxillary sinus • Nasal/sinus endoscopy with frontal sinus exploration with or without removal of tissue • Nasal/sinus endoscopy with sphenoidotomy o Nasal/sinus endoscopy with sphenoidotomy with removal of tissue from the sphenoid sinus • 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 2.02.507 • Coronary angiography without left heart catheterization o Coronary and bypass graft angiography without left heart catheterization • Coronary angiography with right heart catheterization o Coronary and bypass graft angiography with right heart catheterization • Coronary angiography with left heart catheterization o Coronary and bypass graft angiography with left heart catheterization • Coronary angiography with right and left heart catheterization o Coronary and bypass graft angiography with right and left heart catheterization Knee Surgeries Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 7.01.570 • Open osteochondral knee allograft o Arthroscopic osteochondral knee allograft • Open osteochondral knee autograft o Arthroscopic osteochondral knee autograft • Open osteochondral ankle allograft Page | 5 of 16 ∞ Knee Surgeries Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 7.01.569 • Knee arthroscopy for harvesting of cartilage (chondrocyte cells) • Implantation of autologous cultured chondrocytes Knee Arthroscopy in Adults 7.01.549 • Knee arthroscopy lavage and drainage for infection • Knee arthroscopy with lateral release • Knee arthroscopy for removal of loose or foreign body • Knee arthroscopy limited synovectomy o Knee arthroscopy major synovectomy, 2 or more compartments • Knee arthroscopy chondroplasty (debridement/shaving of articular cartilage) • 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