Anthem Blue Cross ConnecticutCommercial Clinical Policy

CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries Form

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Comprehensive blood counts (CBC, WBC, PT/PTT, metabolic panel)

Indications

(2353) Is the preoperative evaluation before a low risk invasive procedure or non-cardiac surgery? 
(2354) Is the patient 65 years of age or older? 
(2355) For patients less than 65 years of age, do they have risk factors for postoperative complications or symptoms suggestive of a significant systemic disease process (ASA III or IV)? 
(2356) Have the same tests not been performed in the previous 30 days? 

Contraindications

(2357) Is the patient between 16 and 65 years of age, asymptomatic, without significant systemic disease (ASA I or II), and had the same tests done within the last 30 days? 
YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the appropriate use of preoperative testing for certain elective, low risk invasive procedures and non-cardiac surgeries. The specific tests included in this document are complete blood count (CBC), white blood cell count (WBC), prothrombin time (PT)/ partial thromboplastin time (PTT), metabolic panel, urinalysis, chest x-rays, resting electrocardiogram (ECG), resting echocardiogram and pre-procedure consultations.  

Clinical Indications

Medically Necessary:

Preoperative testing is considered medically necessary when ALL the following criteria are met (A, B, and C):

  1. Preoperative testing may include any, or all, of the following when done as part of a preoperative evaluation before low risk invasive procedures or non-cardiac surgeries:
    1. Comprehensive blood counts (CBC, WBC, PT/PTT, metabolic panel);
    2. Urinalysis;
    3. Chest X-rays;
    4. Resting ECG;
    5. Resting echocardiogram;
    6. Pre-procedure consultations.
      and
  2. Low risk invasive procedures and surgeries may include the following when criteria are met:
    1. Cataract surgery;
    2. Glaucoma surgery;
    3. Upper endoscopy;
    4. Colonoscopy;
    5. Cystoscopy;
    6. Arthroscopy.
      and
  3. Preoperative testing is considered medically necessary for persons 65 years of age or older or for persons less than 65 years of age with risk factors for postoperative complications or symptoms suggestive of a significant systemic disease process (ASA III or IV*) when the same tests have not been performed in the previous 30 days and when ANY of the following conditions are present:
    1. Anemia; or
    2. Bleeding disorders; or
    3. Other hematologic disorders; or
    4. Cardiovascular disease; or
    5. Pulmonary disease; or
    6. Renal disease; or
    7. Liver disease; or
    8. Endocrine disease; or
    9. Malignancy; or
    10. Hypertension; or
    11. Diabetes; or
    12. Recent upper respiratory infection; or
    13. History of smoking; or
    14. History of alcohol abuse; or
    15. History of steroid use; or
    16. History of anticoagulant therapy.

Note: *For definitions of American Society of Anesthesiologists (ASA) physical status classifications, see the Definitions section.

Not Medically Necessary:

Preoperative testing is considered not medically necessary when ALL of the following criteria are met:

  • Age between 16 and 65 years of age; and
  • When the same tests have been performed within 30 days prior to the planned procedure; and
  • Asymptomatic persons without significant systemic disease (ASA I or II*) of any system or risk factors for postoperative complications.