Prior authorization request form Form

Site of Service Utilization

Effective Date: August 1, 2025 Number: MG.MM.AD.19aC2v4

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Note: The Site of Service Utilization policy is applied only to members under 75 years of age. There is no impact to members 75 years of age and over.

Background This Utilization Review Guideline provides assistance in interpreting EmblemHealth benefit plans. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Utilization Review Guideline is based. In the event of a conflict, the member specific benefit plan document supersedes this Utilization Review Guideline. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Utilization Review Guideline. Other Policies and Guidelines may apply. ConnectiCare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary. This Utilization Review Guideline is provided for informational purposes. It does not constitute medical advice.

Benefit Considerations Before using this guideline, please check the member specific benefit plan document and any federal or state mandates, if applicable. Preauthorization requirements apply to EmblemHealth plans that require services to be medically necessary and conducted in an optimal clinical setting. The medical necessity of the procedure may be separately reviewed against the appropriate criteria. Refer to the member specific benefit plan document to determine if medical necessity applies.

Coverage Rationale 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, 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. 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 or providers office. When there is more than one option for the site of surgery, and in the absence of any clinical contra-indication, the lowest level of site will be approved (i.e., physician office first, then ASC, then hospital outpatient, and last, hospital inpatient). The following will be considered to determine whether the elective procedure is being performed in an optimal clinical setting:  Member’s specific benefit plan  Geographic availability of an in-network provider  Ambulatory surgical care (ASC) capability  Physician privileging  Significant member comorbidities (see list of examples of Qualifying Conditions below)  American Society of Anesthesiologist (ASA) physical status (PS), classification system Potential Documentation Requirements  Physician office notes  Physician privileging  ASA score

Office Based Procedures Except for the following qualifying conditions, most elective procedures should be performed in an Office setting (not an all-inclusive list):  Patient is unable to cooperate with procedure due to mental status, severe anxiety, or extreme pain sensitivity  Failed office-based procedure attempt due to body habitus, abnormal anatomy, or technical difficulties  Bleeding disorder that would cause a significant risk of morbidity  Allergy to local anesthetic  The following will be considered to determine whether the elective procedure is being performed in an optimal clinical setting:  The individual has clinical conditions which may compromise the safety of an office-based procedure, including but not limited to: o Medical conditions which require enhanced monitoring, medications or prolonged recovery period; or o Increased risk for complications due to severe comorbidity, such as that evidenced by an American Society or Anesthesiologist’s (ASA) class III or higher physical status.

ASC and Outpatient Surgical Procedures Except for the qualifying conditions below, many elective procedures should be performed in an Ambulatory Surgical Center (ASC). Some patients may require more complex care due to factors such as age or medical conditions. Also, some ASCs may have specific guidelines that prohibit members who are above a certain weight or have certain health conditions from receiving care in those facilities. Patients with severe systemic disease and some functional limitation (ASA PS classification III or higher) may be appropriate to have the procedure in an outpatient hospital setting (not an all – inclusive list):  Morbid obesity (>BMI.40)  Diabetes (brittle diabetes)  Resistant hypertension (poorly controlled)  Chronic obstructive pulmonary disease (COPD) (FEV1 <50%)  Advance liver disease (MELD Score >8)  Alcohol dependence (at risk for withdrawal syndrome)  End stage renal disease (hyperkalemia (above reference range peritoneal or hemodialysis)  Uncompensated chronic heart failure (CHF) (NYHA class III or IV)  History of myocardial infarction (MI) (recent event (<3 mo.))  History of cerebrovascular accident (CVA) or transient ischemic attack (TIA)  (recent event (<3 mo.))  Coronary artery disease (CAD/peripheral vascular disease (PVD) (ongoing cardiac ischemia requiring medical management recently placed drug eluting stent (within 1 year))  Sleep apnea (mode rate to severe obstructive sleep apnea (OSA)  Implanted pacemaker  Personal history or family history of complication of anesthesia such as malignant hyperthermia  Pregnancy  Bleeding disorder requiring replacement factor or blood products or special infusion  products to correct a coagulation defect (DDAVP is not blood product and is OK)  Prolonged surgery (>3 hrs.)  Anticipated need for transfusion  Recent history of drug abuse (especially cocaine)  Patients with drug eluting stents (DES) placed within one year or bare metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid (ASA) and antiplatelet drugs will be continued by agreement of surgeon, cardiologist and anesthesia  Ongoing evidence of myocardial ischemia  Poorly controlled asthma (FEV1 <80% despite medical management)  Significant valvular heart disease  Cardiac arrhythmia (symptomatic arrhythmia despite medication)  Potentially difficult airway  Uncontrolled seizure disorder

Inpatient Surgical Procedures Certain specific complex surgeries can only be performed in an inpatient setting due to the needed level of involvement of specialized staff and technical equipment necessary to safely perform the procedure. Examples include organ transplants, most oncology procedures and many cardiac procedures.

Coding

CPT/HCPCS Code Description
11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm 11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm 11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11422 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm 11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm 11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm 11622 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm 11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; 11772 Excision of pilonidal cyst or sinus; complicated 12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less 12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm 13152 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 15733 Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) 15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 20694 Removal, under anesthesia, of external fixation system 21012 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater 21013 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm 21014 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater 21315 Closed treatment of nasal bone fracture with manipulation; without stabilization 21555 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm 21556 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm 21931 Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater 23071 Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) 24071 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater

CPT/HCPCS Code Description
24105 Excision, olecranon bursa 25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease) 25073 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greater 25075 Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm 25076 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm 25607 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation 25608 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments 26055 Tendon sheath incision (eg, for trigger finger) 26116 Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cm 26160 Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger 26540 Repair of collateral ligament, metacarpophalangeal or interphalangeal joint 26615 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone 26650 Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation 26727 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure 27337 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater 27339 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) 28005 Incision, bone cortex (eg, osteomyelitis or bone abscess), foot 28010 Tenotomy, percutaneous, toe; single tendon 28041 Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); 1.5 cm or greater 28090 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot 28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) 28120 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus 28124 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe 28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant 28295 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method 28296 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method 28299 Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy 29823 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])

CPT/HCPCS Code Description
29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction 30130 Excision inferior turbinate, partial or complete, any method 30140 Submucous resection inferior turbinate, partial or complete, any method 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope 31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) 36561 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older 36589 Removal of tunneled central venous catheter, without subcutaneous port or pump 38525 Biopsy or excision of lymph node(s); open, deep axillary node(s) 41520 Frenoplasty (surgical revision of frenum, eg, with Z-plasty) 42820 Tonsillectomy and adenoidectomy; younger than age 12 42825 Tonsillectomy, primary or secondary; younger than age 12 42826 Tonsillectomy, primary or secondary; age 12 or over 43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire 43251 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) 43450 Dilation of esophagus, by unguided sound or bougie, single or multiple passes 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) 44361 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple 44386 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple

CPT/HCPCS Code Description
45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45390 Colonoscopy, flexible; with endoscopic mucosal resection 46040 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) 46221 Hemorrhoidectomy, internal, by rubber band ligation(s) 46255 Hemorrhoidectomy, internal and external, single column/group; 46607 Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple 47562 Laparoscopy, surgical; cholecystectomy 47563 Laparoscopy, surgical; cholecystectomy with cholangiography 49322 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) 49505 Repair initial inguinal hernia, age 5 years or older; reducible 49591 Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible 49650 Laparoscopy, surgical; repair initial inguinal hernia 49651 Laparoscopy, surgical; repair recurrent inguinal hernia 50590 Lithotripsy, extracorporeal shock wave 52235 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) 52281 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female 52287 Cystourethroscopy, with injection(s) for chemodenervation of the bladder 52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple 52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) 52352 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) 52354 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion 52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type) 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block 55040 Excision of hydrocele; unilateral 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 56405 Incision and drainage of vulva or perineal abscess 56501 Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) 56605 Biopsy of vulva or perineum (separate procedure); 1 lesion 57288 Sling operation for stress incontinence (eg, fascia or synthetic) 57452 Colposcopy of the cervix including upper/adjacent vagina; 57454 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage 57500 Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 57522 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision

CPT/HCPCS Code Description
58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C 58563 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) 64718 Neuroplasty and/or transposition; ulnar nerve at elbow 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel 65756 Keratoplasty (corneal transplant); endothelial 65855 Trabeculoplasty by laser surgery 66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) 66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages) 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation 66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal 67028 Intravitreal injection of a pharmacologic agent (separate procedure) 67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation 67042 Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) 67107 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid 67108 Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique 67113 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens 67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage; photocoagulation 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation 67228 Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation 67311 Strabismus surgery, recession or resection procedure; 1 horizontal muscle 67400 Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy 68811 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia 68815 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent 69610

Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch 69645 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction

References American Heart Association. Classes of Heart Failure. Available at: http://www.heart.org/en/health-topics/heart- failure/what-is-heart-failure/classes-of-heart-failure. Accessed April 18, 2025. ASA Physical Status Classification System. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long - term care of obstructive sleep apnea in adults. JClin Sleep Med. 2009 Jun 15; 5(3):263-76. Available at: http://www.aasmnet.org/. Accessed April 18, 2025. Friedman L S. Surgery in the Patient with Liver Disease. Trans Am Clin Climatol Assoc. 2010; 121: 192–205. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917124/. Accessed April 18, 2025. American College of Surgeons. Patient safety principles for office-based surgery. September 1, 2019. https://www.facs.org/about-acs/statements/patient-safety-principles-for-office-based-surgery-utilizing-moderate- sedation-analgesia/. Accessed April 18, 2025. American Society of American Society of Anesthesiologists. Guidelines for office-based anesthesia. Statement on Office- Based Anesthesia. Original Approval: October 13, 1999. Last amended October 23, 2024. https://www.asahq.org/standards-and-practice-parameters/statement-on-office-based-anesthesia. Accessed April 18,

2025. Federation of State Medical Boards of the United States, Inc. Report of the Special Committee on outpatient (office- based) surgery. 2002. http://www.fsmb.org/siteassets/advocacy/policies/outpatient-office-based-surgery.pdf. Accessed April 18, 2025

      Revision History

      Aug 1, 2025 Policy updated:

      • Four codes removed effective 8/1/2025: 19120, 19125, 19307 and 44970
      • Policy corrected to include applicable codes effective 8/1/2025 Policy reinstated with:
      • Clarification to member age applicability
      • Updated coding and Place of Service column-removal from Coding Table Apr 14, 2023 Policy retired May 27, 2022 Added note communicating that the policy is applied only to members between 18–74 years of age Jan. 10, 2020 Expanded from Commercial and Medicaid only to include Medicare applicability eff. Feb 1, 2020