MedicaidApril 23, 2024
Clarification of expansion of outpatient surgery redirection procedures
On February 11, we notified you of the below change in outpatient surgery procedures here: Expansion of outpatient surgery redirection procedures. Please use this notification as a clarification on what is required for medical necessity.
Effective April 1, 2024, all outpatient procedures and surgeries listed below should be conducted in a freestanding, unregulated, facility. This update is applicable in Anne Arundel County, Baltimore City, Baltimore County, Carroll County, Howard County, Montgomery County, Prince George's County, and District of Columbia for members 18 years of age and above.
In Maryland, where the availability and accessibility of surgery in unregulated space supports the access needs of our members, these services will require review and precertification of the site-of-service when hospital outpatient, or regulated, site of service is requested.
When medical necessity of the service is met for those services requiring medical necessity review, the services will then require review and precertification of the site-of-service (when hospital outpatient or regulated, site of service is requested).
All service authorization requests will be processed according to state requirements.
Definitions:
- Administrative denial for site of service: The denial for payment of a requested site or place of service for reasons other than a lack of medical necessity
- Freestanding facilities: In Maryland, freestanding facilities are defined as practices that render services in unregulated, non-hospital space
- Medical necessity: Refers to activities that may be justified as reasonable, necessary, or appropriate based on objective and evidenced-based clinical standards of care. Examples of criteria that are the basis for the determination that a service, procedure, or supply is medically necessary include but are not limited to:
- Precertification: Process by which medical necessity criteria are applied to ensure that proposed care is medically necessary and performed at the appropriate level of care
- Site of service review: Once medical necessary has been determined for the requested procedure or service, a site of service administrative review will be required to ensure the service will be provided in the most efficient and cost-effective setting.
Impacted CPT®/HCPCS codes:
Code | Description |
Otolaryngology | |
30000 | DRAINAGE OF NOSE LESION |
30020 | DRAINAGE OF NOSE LESION |
30100 | INTRANASAL BIOPSY |
30110 | REMOVAL OF NOSE POLYP(S) |
30115 | REMOVAL OF NOSE POLYP(S) |
30117 | REMOVAL OF INTRANASAL LESION |
30118 | REMOVAL OF INTRANASAL LESION |
30130 | EXCISE INFERIOR TURBINATE |
30140 | RESECT INFERIOR TURBINATE |
30220 | INSERT NASAL SEPTAL BUTTON |
30310 | REMOVE NASAL FOREIGN BODY |
30520 | REPAIR OF NASAL SEPTUM |
30580 | REPAIR UPPER JAW FISTULA |
30630 | REPAIR NASAL SEPTUM DEFECT |
30801 | ABLATE INF TURBINATE SUPERF |
30802 | ABLATE INF TURBINATE SUBMUC |
30901 | CONTROL OF NOSEBLEED |
30903 | CONTROL OF NOSEBLEED |
30930 | THER FX NASAL INF TURBINATE |
31020 | EXPLORATION MAXILLARY SINUS |
31030 | EXPLORATION MAXILLARY SINUS |
31032 | EXPLORE SINUS REMOVE POLYPS |
31200 | REMOVAL OF ETHMOID SINUS |
31205 | REMOVAL OF ETHMOID SINUS |
31525 | DX LARYNGOSCOPY EXCL NB |
31526 | DX LARYNGOSCOPY W/OPER SCOPE |
31528 | LARYNGOSCOPY AND DILATION |
31529 | LARYNGOSCOPY AND DILATION |
31530 | LARYNGOSCOPY W/FB REMOVAL |
31535 | LARYNGOSCOPY W/BIOPSY |
31536 | LARYNGOSCOPY W/BX & OP SCOPE |
31540 | LARYNGOSCOPY W/EXC OF TUMOR |
31541 | LARYNSCOP W/TUMR EXC + SCOPE |
31545 | REMOVE VC LESION W/SCOPE |
31570 | LARYNGOSCOPE W/VC INJ |
31571 | LARYNGOSCOP W/VC INJ + SCOPE |
31574 | LARGSC W/NJX AUGMENTATION |
31576 | LARYNGOSCOPY WITH BIOPSY |
31578 | LARGSC W/REMOVAL LESION |
31591 | LARYNGOPLASTY MEDIALIZATION |
31611 | SURGERY/SPEECH PROSTHESIS |
69000 | DRAIN EXTERNAL EAR LESION |
69100 | BIOPSY OF EXTERNAL EAR |
69140 | REMOVE EAR CANAL LESION(S) |
69145 | REMOVE EAR CANAL LESION(S) |
69205 | CLEAR OUTER EAR CANAL |
69222 | CLEAN OUT MASTOID CAVITY |
General surgery | |
19020 | INCISION OF BREAST LESION |
19120 | REMOVAL OF BREAST LESION |
19125 | EXCISION BREAST LESION |
20551 | INJ TENDON ORIGIN/INSERTION |
20552 | INJ TRIGGER POINT 1/2 MUSCL |
20553 | INJECT TRIGGER POINTS 3/> |
21011 | EXC FACE LES SC <2 CM |
21012 | EXC FACE LES SBQ 2 CM/> |
21013 | EXC FACE TUM DEEP < 2 CM |
21014 | EXC FACE TUM DEEP 2 CM/> |
21552 | EXC NECK LES SC 3 CM/> |
21554 | EXC NECK TUM DEEP 5 CM/> |
21555 | EXC NECK LES SC < 3 CM |
21556 | EXC NECK TUM DEEP < 5 CM |
21930 | EXC BACK LES SC < 3 CM |
21931 | EXC BACK LES SC 3 CM/> |
22902 | EXC ABD LES SC < 3 CM |
22903 | EXC ABD LES SC 3 CM/> |
36000 | PLACE NEEDLE IN VEIN |
36010 | PLACE CATHETER IN VEIN |
36012 | PLACE CATHETER IN VEIN |
36215 | PLACE CATHETER IN ARTERY |
36246 | INS CATH ABD/L-EXT ART 2ND |
36569 | INSJ PICC 5 YR+ W/O IMAGING |
36821 | AV FUSION DIRECT ANY SITE |
36901 | INTRO CATH DIALYSIS CIRCUIT |
36902 | INTRO CATH DIALYSIS CIRCUIT |
37761 | LIGATE LEG VEINS OPEN |
37765 | STAB PHLEB VEINS XTR 10-20 |
37766 | PHLEB VEINS - EXTREM 20+ |
37785 | LIGATE/DIVIDE/EXCISE VEIN |
38221 | DX BONE MARROW BIOPSIES |
38222 | DX BONE MARROW BX & ASPIR |
38505 | NEEDLE BIOPSY LYMPH NODES |
40490 | BIOPSY OF LIP |
40510 | PARTIAL EXCISION OF LIP |
40520 | PARTIAL EXCISION OF LIP |
40808 | BIOPSY OF MOUTH LESION |
40810 | EXCISION OF MOUTH LESION |
40812 | EXCISE/REPAIR MOUTH LESION |
40814 | EXCISE/REPAIR MOUTH LESION |
40816 | EXCISION OF MOUTH LESION |
41010 | INCISION OF TONGUE FOLD |
41100 | BIOPSY OF TONGUE |
41105 | BIOPSY OF TONGUE |
41108 | BIOPSY OF FLOOR OF MOUTH |
41110 | EXCISION OF TONGUE LESION |
41112 | EXCISION OF TONGUE LESION |
41113 | EXCISION OF TONGUE LESION |
41116 | EXCISION OF MOUTH LESION |
41825 | EXCISION OF GUM LESION |
42100 | BIOPSY ROOF OF MOUTH |
42104 | EXCISION LESION MOUTH ROOF |
42106 | EXCISION LESION MOUTH ROOF |
42107 | EXCISION LESION MOUTH ROOF |
42330 | REMOVAL OF SALIVARY STONE |
42335 | REMOVAL OF SALIVARY STONE |
42405 | BIOPSY OF SALIVARY GLAND |
42408 | EXCISION OF SALIVARY CYST |
42410 | EXCISE PAROTID GLAND/LESION |
42415 | EXCISE PAROTID GLAND/LESION |
42420 | EXCISE PAROTID GLAND/LESION |
42425 | EXCISE PAROTID GLAND/LESION |
42440 | EXCISE SUBMAXILLARY GLAND |
42450 | EXCISE SUBLINGUAL GLAND |
42500 | REPAIR SALIVARY DUCT |
42800 | BIOPSY OF THROAT |
42804 | BIOPSY OF UPPER NOSE/THROAT |
Gastroenterology | |
43197 | ESOPHAGOSCOPY FLEX DX BRUSH |
43214 | ESOPHAGOSC DILATE BALLOON 30 |
43229 | ESOPHAGOSCOPY LESION ABLATE |
43233 | EGD BALLOON DIL ESOPH30 MM/> |
43236 | UPPR GI SCOPE W/SUBMUC INJ |
43254 | EGD ENDO MUCOSAL RESECTION |
43450 | DILATE ESOPHAGUS 1/MULT PASS |
43453 | DILATE ESOPHAGUS |
45100 | BIOPSY OF RECTUM |
45171 | EXC RECT TUM TRANSANAL PART |
45172 | EXC RECT TUM TRANSANAL FULL |
45190 | DESTRUCTION RECTAL TUMOR |
45346 | SIGMOIDOSCOPY W/ABLATION |
45349 | SIGMOIDOSCOPY W/RESECTION |
45350 | SGMDSC W/BAND LIGATION |
45905 | DILATION OF ANAL SPHINCTER |
45910 | DILATION OF RECTAL NARROWING |
45915 | REMOVE RECTAL OBSTRUCTION |
45990 | SURG DX EXAM ANORECTAL |
46020 | PLACEMENT OF SETON |
46040 | INCISION OF RECTAL ABSCESS |
46045 | INCISION OF RECTAL ABSCESS |
46050 | INCISION OF ANAL ABSCESS |
46060 | INCISION OF RECTAL ABSCESS |
46083 | INCISE EXTERNAL HEMORRHOID |
46200 | REMOVAL OF ANAL FISSURE |
46220 | EXCISE ANAL EXT TAG/PAPILLA |
46230 | REMOVAL OF ANAL TAGS |
46257 | REMOVE IN/EX HEM GRP & FISS |
46261 | REMOVE IN/EX HEM GRPS & FISS |
46262 | REMOVE IN/EX HEM GRPS W/FIST |
46270 | REMOVE ANAL FIST SUBQ |
46275 | REMOVE ANAL FIST INTER |
46320 | REMOVAL OF HEMORRHOID CLOT |
46505 | CHEMODENERVATION ANAL MUSC |
46607 | DIAGNOSTIC ANOSCOPY & BIOPSY |
46700 | REPAIR OF ANAL STRICTURE |
46706 | REPR OF ANAL FISTULA W/GLUE |
46707 | REPAIR ANORECTAL FIST W/PLUG |
46750 | REPAIR OF ANAL SPHINCTER |
46910 | DESTRUCTION ANAL LESION(S) |
46917 | LASER SURGERY ANAL LESIONS |
46922 | EXCISION OF ANAL LESION(S) |
46924 | DESTRUCTION ANAL LESION(S) |
46930 | DESTROY INTERNAL HEMORRHOIDS |
46940 | TREATMENT OF ANAL FISSURE |
46945 | INT HRHC LIG 1 HROID W/O IMG |
46946 | INT HRHC LIG 2+HROID W/O IMG |
46947 | HEMORRHOIDOPEXY BY STAPLING |
46948 | INT HRHC TRANAL DARTLZJ 2+ |
47000 | NEEDLE BIOPSY OF LIVER |
49082 | ABD PARACENTESIS |
49422 | REMOVE TUNNELED IP CATH |
49500 | RPR ING HERNIA INIT REDUCE |
49570 | RPR EPIGASTRIC HERN REDUCE |
49585 | RPR UMBIL HERN REDUC > 5 YR |
Opthamology | |
65710 | CORNEAL TRANSPLANT |
65730 | CORNEAL TRANSPLANT |
65750 | CORNEAL TRANSPLANT |
65755 | CORNEAL TRANSPLANT |
65756 | CORNEAL TRNSPL ENDOTHELIAL |
67105 | REPAIR DETACHED RETINA PC |
67107 | REPAIR DETACHED RETINA |
67108 | REPAIR DETACHED RETINA |
67145 | PROPH RTA DTCHMNT PC |
68811 | PROBE NASOLACRIMAL DUCT |
Orthopedic surgery | |
20520 | REMOVAL OF FOREIGN BODY |
20525 | REMOVAL OF FOREIGN BODY |
20526 | THER INJECTION CARP TUNNEL |
23030 | DRAIN SHOULDER LESION |
23071 | EXC SHOULDER LES SC 3 CM/> |
23075 | EXC SHOULDER LES SC < 3 CM |
23120 | PARTIAL REMOVAL COLLAR BONE |
23140 | REMOVAL OF BONE LESION |
23150 | REMOVAL OF HUMERUS LESION |
24000 | EXPLORATORY ELBOW SURGERY |
24006 | RELEASE ELBOW JOINT |
24071 | EXC ARM/ELBOW LES SC 3 CM/> |
24075 | EXC ARM/ELBOW LES SC < 3 CM |
24101 | EXPLORE/TREAT ELBOW JOINT |
24102 | REMOVE ELBOW JOINT LINING |
24105 | REMOVAL OF ELBOW BURSA |
24110 | REMOVE HUMERUS LESION |
24120 | REMOVE ELBOW LESION |
24310 | REVISION OF ARM TENDON |
24357 | REPAIR ELBOW PERC |
24358 | REPAIR ELBOW W/DEB OPEN |
24366 | RECONSTRUCT HEAD OF RADIUS |
24515 | TREAT HUMERUS FRACTURE |
24516 | TREAT HUMERUS FRACTURE |
24586 | TREAT ELBOW FRACTURE |
24615 | TREAT ELBOW DISLOCATION |
24665 | TREAT RADIUS FRACTURE |
24666 | TREAT RADIUS FRACTURE |
25000 | INCISION OF TENDON SHEATH |
25071 | EXC FOREARM LES SC 3 CM/> |
25073 | EXC FOREARM TUM DEEP 3 CM/> |
25075 | EXC FOREARM LES SC < 3 CM |
25076 | EXC FOREARM TUM DEEP < 3 CM |
25085 | INCISION OF WRIST CAPSULE |
25110 | REMOVE WRIST TENDON LESION |
25115 | REMOVE WRIST/FOREARM LESION |
25118 | EXCISE WRIST TENDON SHEATH |
25120 | REMOVAL OF FOREARM LESION |
25130 | REMOVAL OF WRIST LESION |
25260 | REPAIR FOREARM TENDON/MUSCLE |
25270 | REPAIR FOREARM TENDON/MUSCLE |
25275 | REPAIR FOREARM TENDON SHEATH |
25280 | REVISE WRIST/FOREARM TENDON |
25290 | INCISE WRIST/FOREARM TENDON |
25295 | RELEASE WRIST/FOREARM TENDON |
25350 | REVISION OF RADIUS |
25545 | TREAT FRACTURE OF ULNA |
25605 | TREAT FRACTURE RADIUS/ULNA |
25606 | TREAT FX DISTAL RADIAL |
25607 | TREAT FX RAD EXTRA-ARTICUL |
25608 | TREAT FX RAD INTRA-ARTICUL |
25609 | TREAT FX RADIAL 3+ FRAG |
25624 | TREAT WRIST BONE FRACTURE |
25628 | TREAT WRIST BONE FRACTURE |
25635 | TREAT WRIST BONE FRACTURE |
25645 | TREAT WRIST BONE FRACTURE |
25652 | TREAT FRACTURE ULNAR STYLOID |
26011 | DRAINAGE OF FINGER ABSCESS |
26020 | DRAIN HAND TENDON SHEATH |
26045 | RELEASE PALM CONTRACTURE |
26055 | INCISE FINGER TENDON SHEATH |
26070 | EXPLORE/TREAT HAND JOINT |
26075 | EXPLORE/TREAT FINGER JOINT |
26080 | EXPLORE/TREAT FINGER JOINT |
26105 | BIOPSY FINGER JOINT LINING |
26110 | BIOPSY FINGER JOINT LINING |
26111 | EXC HAND LES SC 1.5 CM/> |
26113 | EXC HAND TUM DEEP 1.5 CM/> |
26115 | EXC HAND LES SC < 1.5 CM |
26116 | EXC HAND TUM DEEP < 1.5 CM |
26160 | REMOVE TENDON SHEATH LESION |
26180 | REMOVAL OF FINGER TENDON |
26200 | REMOVE HAND BONE LESION |
26210 | REMOVAL OF FINGER LESION |
26236 | PARTIAL REMOVAL FINGER BONE |
26320 | REMOVAL OF IMPLANT FROM HAND |
26432 | REPAIR FINGER TENDON |
26433 | REPAIR FINGER TENDON |
26437 | REALIGNMENT OF TENDONS |
26440 | RELEASE PALM/FINGER TENDON |
26442 | RELEASE PALM & FINGER TENDON |
26445 | RELEASE HAND/FINGER TENDON |
26455 | INCISION OF FINGER TENDON |
26516 | FUSION OF KNUCKLE JOINT |
26520 | RELEASE KNUCKLE CONTRACTURE |
26525 | RELEASE FINGER CONTRACTURE |
26530 | REVISE KNUCKLE JOINT |
26535 | REVISE FINGER JOINT |
26540 | REPAIR HAND JOINT |
26608 | TREAT METACARPAL FRACTURE |
26615 | TREAT METACARPAL FRACTURE |
26650 | TREAT THUMB FRACTURE |
26665 | TREAT THUMB FRACTURE |
26676 | PIN HAND DISLOCATION |
26715 | TREAT KNUCKLE DISLOCATION |
26727 | TREAT FINGER FRACTURE EACH |
26735 | TREAT FINGER FRACTURE EACH |
26742 | TREAT FINGER FRACTURE EACH |
26746 | TREAT FINGER FRACTURE EACH |
26756 | PIN FINGER FRACTURE EACH |
26765 | TREAT FINGER FRACTURE EACH |
26841 | FUSION OF THUMB |
26842 | THUMB FUSION WITH GRAFT |
27043 | EXC HIP PELVIS LES SC 3 CM/> |
27047 | EXC HIP/PELVIS LES SC < 3 CM |
27062 | REMOVE FEMUR LESION/BURSA |
27323 | BIOPSY THIGH SOFT TISSUES |
27324 | BIOPSY THIGH SOFT TISSUES |
27327 | EXC THIGH/KNEE LES SC < 3 CM |
27329 | RESECT THIGH/KNEE TUM < 5 CM |
27331 | EXPLORE/TREAT KNEE JOINT |
27334 | REMOVE KNEE JOINT LINING |
27337 | EXC THIGH/KNEE LES SC 3 CM/> |
27340 | REMOVAL OF KNEECAP BURSA |
27345 | REMOVAL OF KNEE CYST |
27347 | REMOVE KNEE CYST |
27372 | REMOVAL OF FOREIGN BODY |
27403 | REPAIR OF KNEE CARTILAGE |
27407 | REPAIR OF KNEE LIGAMENT |
27418 | REPAIR DEGENERATED KNEECAP |
27570 | FIXATION OF KNEE JOINT |
27606 | INCISION OF ACHILLES TENDON |
27613 | BIOPSY LOWER LEG SOFT TISSUE |
27614 | BIOPSY LOWER LEG SOFT TISSUE |
27618 | EXC LEG/ANKLE TUM < 3 CM |
27620 | EXPLORE/TREAT ANKLE JOINT |
27626 | REMOVE ANKLE JOINT LINING |
27632 | EXC LEG/ANKLE LES SC 3 CM/> |
27638 | REMOVE/GRAFT LEG BONE LESION |
27640 | PARTIAL REMOVAL OF TIBIA |
27658 | REPAIR OF LEG TENDON EACH |
27659 | REPAIR OF LEG TENDON EACH |
27665 | REPAIR OF LEG TENDON EACH |
27680 | RELEASE OF LOWER LEG TENDON |
27685 | REVISION OF LOWER LEG TENDON |
27690 | REVISE LOWER LEG TENDON |
27705 | INCISION OF TIBIA |
28291 | CORRJ HALUX RIGDUS W/IMPLT |
28295 | CORRECTION HALLUX VALGUS |
29800 | JAW ARTHROSCOPY/SURGERY |
29804 | JAW ARTHROSCOPY/SURGERY |
29805 | SHO ARTHRS DX +- SYNOVIAL BX |
29819 | SHO ARTHRS SRG RMVL LOOSE/FB |
29820 | SHO ARTHRS SRG PRTL SYNVCT |
29821 | SHO ARTHRS SRG COMPL SYNVCT |
29830 | ELBOW ARTHROSCOPY |
29835 | ELBOW ARTHROSCOPY/SURGERY |
29836 | ELBOW ARTHROSCOPY/SURGERY |
29837 | ELBOW ARTHROSCOPY/SURGERY |
29838 | ELBOW ARTHROSCOPY/SURGERY |
29840 | WRIST ARTHROSCOPY |
29844 | WRIST ARTHROSCOPY/SURGERY |
29845 | WRIST ARTHROSCOPY/SURGERY |
29847 | WRIST ARTHROSCOPY/SURGERY |
29860 | HIP ARTHROSCOPY DX |
29861 | HIP ARTHRO W/FB REMOVAL |
29885 | KNEE ARTHROSCOPY/SURGERY |
29886 | KNEE ARTHROSCOPY/SURGERY |
29887 | KNEE ARTHROSCOPY/SURGERY |
29899 | ANKLE ARTHROSCOPY/SURGERY |
29901 | MCP JOINT ARTHROSCOPY SURG |
29915 | HIP ARTHRO ACETABULOPLASTY |
29916 | HIP ARTHRO W/LABRAL REPAIR |
63661 | REMOVE SPINE ELTRD PERQ ARAY |
63663 | REVISE SPINE ELTRD PERQ ARAY |
64530 | N BLOCK INJ CELIAC PELUS |
64600 | INJECTION TREATMENT OF NERVE |
64610 | INJECTION TREATMENT OF NERVE |
64642 | CHEMODENERV 1 EXTREMITY 1-4 |
64644 | CHEMODENERV 1 EXTREM 5/> MUS |
64646 | CHEMODENERV TRUNK MUSC 1-5 |
64702 | REVISE FINGER/TOE NERVE |
64719 | REVISE ULNAR NERVE AT WRIST |
64774 | REMOVE SKIN NERVE LESION |
64776 | REMOVE DIGIT NERVE LESION |
64782 | REMOVE LIMB NERVE LESION |
64784 | REMOVE NERVE LESION |
64788 | REMOVE SKIN NERVE LESION |
64795 | BIOPSY OF NERVE |
64831 | REPAIR OF DIGIT NERVE |
64835 | REPAIR OF HAND OR FOOT NERVE |
Urology | |
54360 | PENIS PLASTIC SURGERY |
Wound care | |
11000 | DEBRIDE INFECTED SKIN |
11010 | DEBRIDE SKIN AT FX SITE |
11012 | DEB SKIN BONE AT FX SITE |
11770 | REMOVE PILONIDAL CYST SIMPLE |
11772 | REMOVE PILONIDAL CYST COMPL |
11900 | INJECT SKIN LESIONS </W 7 |
12020 | CLOSURE OF SPLIT WOUND |
12031 | INTMD RPR S/A/T/EXT 2.5 CM/< |
12032 | INTMD RPR S/A/T/EXT 2.6-7.5 |
12034 | INTMD RPR S/TR/EXT 7.6-12.5 |
12035 | INTMD RPR S/A/T/EXT 12.6-20 |
12037 | INTMD RPR S/TR/EXT >30.0 CM |
12041 | INTMD RPR N-HF/GENIT 2.5CM/< |
12042 | INTMD RPR N-HF/GENIT2.6-7.5 |
12051 | INTMD RPR FACE/MM 2.5 CM/< |
12052 | INTMD RPR FACE/MM 2.6-5.0 CM |
Procedure: site of service precertifications:
- When an authorization request for specified services/procedures is initiated for services to be performed in an outpatient hospital facility or regulated space and the service meets medical necessity criteria, the requester must also identify any special circumstance(s) to justify why the service must be provided in the hospital-based or regulated setting. If the requester cannot provide a special circumstance, the service will be redirected to a participating freestanding practice/facility.
- When an authorization request meets medical necessity for the service, but no special circumstances are provided (see Definitions) to support the provision of services in a hospital-based or regulated setting and the requesting care provider does not accept redirection to a freestanding or unregulated site of service, then an administrative denial for site of service will be issued. The care provider/member will be notified that the services meet medical necessity for approval, but the site/location of services is being administratively denied. An administrative denial letter will be issued per requirements.
- The member/patient will be notified of the administrative denial for site of service and offered alternative in-network care providers upon request.
Medical Necessity Criteria
List of relevant case or member-specific facts that support the use of hospital-based or regulated space procedures. Reasons may include but are not limited to:
- Ability of a freestanding site of service to safely and adequately accommodate and support the member in the course of treatment because of specialized equipment or staff skill set.
- Access or availability of a freestanding site of service within the 30-minute or 30-mile standard.
- Member is under 18 years of age except as noted for specific specialty procedures (for example, ENT, sleep studies, high-tech radiology, routine laboratory services, infusion drugs, etc.).
- Suffering from any of the following conditions:
- Respiratory disease:
- Asthma (uncontrolled/actively treating)
- Chronic Obstructive Pulmonary Disease/Emphysema (uncontrolled/actively treating)
- Obstructive sleep apnea (OSA) and CPAP/APAP use within past 6 months
- Pediatric members with confirmed OSA (obstructive sleep apnea) and Tonsillectomy & Adenoidectomy planned (no CPAP/APAP use required)
- Cardiac disease:
- Congestive heart failure symptomatic in the last month (any episode of documented or active congestive heart failure, emergency room visit, admission, worsening chronic congestive heart failure, recent adjustment of medicines, etc.)
- Myocardial infarction within the last six weeks
- Arrhythmia within the last six weeks
- Pacemaker in place
- Automatic implantable cardioverter defibrillator in place
- On warfarin or another anticoagulant
- On Plavix® or another platelet inhibitor
- Respiratory disease:
- Severe anemia/Hematocrit <=25% &/or thrombocytopenia, platelets <=150,000
- BMI/Body Mass Index >=40
- Chronic Kidney Disease (CKD) stage 3 or higher
- History of any complication with sedation, anesthesia, or surgery
Reference
Please note, this is not a comprehensive redirection list. These codes are in addition to those included in prior redirection updates. For code-specific precertification requirements, please refer to our Precertification Lookup Tool.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 833-707-0868.
Thank you for the quality care you provide to our members.
Coverage provided by Wellpoint Maryland, Inc.
MDWP-CD-057242-24-SRS56329
PUBLICATIONS: May 2024 Provider Newsletter
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