57460
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.76
Facility
$141.62
Non-Facility
$308.96
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Prior authorization documentation when procedures listed in the Applicable Codes section are not performed in an office setting.
- Documentation supporting the applicable medical necessity criterion for ASC use (e.g., evidence of allergy to local anesthetic; documentation of bleeding disorder with significant morbidity risk; documentation of developmental stage or cognitive status requiring ASC; records of failed office-based procedure attempts due to body habitus, abnormal anatomy, or technical difficulties; documentation of complications and comorbid disease making office-based procedure unsafe or unsuitable).
Key Coverage Criteria
- UnitedHealthcare members may choose to receive surgical procedures in an office setting or other locations. We are conducting site of service medical necessity reviews, however, to determine whether the ambulatory surgical center (ASC) is medically necessary, in accordance with the terms of the member's benefit plan.
- Certain elective procedures performed in an ambulatory surgical center are considered medically necessary for an individual who meets any of the following criteria:
- Allergy to local anesthetic
- Bleeding disorder that would cause a significant risk of morbidity
- Developmental stage or cognitive status warranting use of an ambulatory surgical center
- Failed office-based procedure attempts due to body habitus, abnormal anatomy, or technical difficulties
2 Active Policies
UHC-POL-office-based-procedures-site-service — Office-Based Procedures – Site of Service
UMR-POL-UMR-office-based-procedures-site-service — Office-Based Procedures – Site of Service
Related Codes
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