This document addresses the clinical features that may increase an individual’s risk of requiring urgent access to care available in a hospital outpatient department, hospital outpatient clinic, or hospital-based outpatient surgery facility during outpatient procedures, including but not limited to endoscopic services.

Note:
In some plans, “level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of, or in addition to, “site of care” and, in some plans, these terms may be used interchangeably.

Note: Please see the following related documents for additional information:

• CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
• CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
• CG-MED-83 Site of Care: Specialty Pharmaceuticals
• CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures

Note: This guideline will be used for the evaluation of a subset of ambulatory procedures that will be determined and posted by individual lines of business. The medical necessity of the procedure may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of an outpatient hospital facility site of care for the procedure. This guideline is not for determination of the medical necessity of inpatient site of care.

Medically Necessary:

1. An outpatient surgery, including but not limited to endoscopic services, in a hospital-based facility is considered medically necessary when all of the following are present:
   1. The procedure requires that it be performed only by, or under, the general supervision of a licensed clinician; and
   2. The individual's medical status or the procedure requires enhanced monitoring beyond what would routinely be needed for rendering such services in a free-standing ambulatory procedural setting; and
   3. The potential changes in the individual's medical status could require immediate access to specific services of a medical center/hospital setting, such as emergency resuscitation equipment and personnel, and inpatient admission or intensive care. For example, the individual is at significant risk of sudden life-threatening changes in medical status based on clinical conditions including but not limited to:
      1. concerns regarding fluid overload status; or
      2. history of significant instability during a prior procedure that is considered a risk for other future procedures; or
      3. at risk for excessive bleeding; or
      4. acute mental status changes; or
      5. under the age of 18; or
      6. pregnancy; or
      7. increased risk for complication due to severe comorbidity, such as that evidenced by an American Society of Anesthesiologist’s (ASA) class III physical status or greater; or
      8. prolonged anesthesia is anticipated.
2. An outpatient surgery, including but not limited to endoscopic services, in a hospital-based facility is considered medically necessary when there are no other geographically accessible appropriate alternative sites for the member to undergo the procedure.

Not Medically Necessary:

All other uses of a hospital-based facility for an outpatient procedure are considered not medically necessary.