POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

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1 Original Issue Date (Created): 1/5/2015 Most Recent Review Date (Revised): 11/24/2015 Effective Date: 12/5/2016 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Minor surgical and other procedures that are generally safe to perform in the provider s office (see guidelines) may be considered medically necessary to be performed in an outpatient facility setting when the following medical criteria are met: 1. The equipment necessary is typically not available in an office setting (i.e. fluoroscopy or Ultrasound for large joint injection), or 2. There is a high probability of complication due to concomitant systemic disease for which the patient is under current medical management and which significantly increases the probability of complications (e.g. unstable heart disease, severe asthma, severe chronic obstructive pulmonary disease, seizures, hemophilia); or 3. Patients (adult or children) who have a history of severe postoperative complications following minor surgical procedures, or 4. When general anesthesia is required for the safe and effective completion of the procedure When it is medically necessary that the services be provided in a setting other than an office, the outpatient facility may be hospital based or free-standing. The use of outpatient facility setting is considered not medically necessary when performing a minor surgical or other procedure in the following situations: For the convenience of the provider or patient, or Due to phobias or anxiety Due to the religious affiliation of the provider s office Page 1

2 Guidelines: Examples of surgical and other procedures typically safely performed in the Office setting, (this list is representative and not all inclusive): Arthrocentesis Aspiration of a joint Colposcopy Electrodessication condylomata Excision of a Chalazion Excision of a nail Enucleation/Excision of external thrombosed hemorrhoid Injection of a ligament or tendon Intraocular Injections Oral surgery (to include but not limited to simple dental extractions) Removal of partial or complete bony impacted teeth Pain management to include: o Trigger point injections o Peripheral nerve blocks Proctosigmoidoscopy Flexible sigmoidoscopy Repair of lacerations, including suturing 2.5cm or less Vasectomy Wound care and dressing to include outpatient burn care Cross References: MP Dental and Oral Procedures Performed in a Facility MP Intravitreal Angiogenesis Inhibitors for Eye Conditions II. PRODUCT VARIATIONS This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. III. DESCRIPTION/BACKGROUND Most minor surgical and other procedures can usually be provided in an office setting. However, hospital outpatient facility or ambulatory surgery center facilities may be indicated in some situations. Page 2

3 IV. RATIONALE NA V. DEFINITIONS Outpatient Facility Outpatient Hospital or Ambulatory Surgery Center VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Page 3

4 Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code C9257 D7210 D7220 D7230 D7240 D7241 D7250 D7270 D7285 D7410 D7413 D7440 D7450 D7460 D7465 D7471 D7472 Description Injection, bevacizumab, 0.25 mg Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated; Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure. Removal of impacted tooth - soft tissue; Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. Removal of impacted tooth - partially bony; Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Removal of impacted tooth - completely bony; Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Removal of impacted tooth - completely bony, with unusual surgical complications; Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position. Surgical removal of residual tooth roots (cutting procedure); Includes cutting of soft tissue and bone, removal of tooth structure, and closure. Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; Includes splinting and/or stabilization. Biopsy of oral tissue - hard (bone, tooth); For removal of specimen only. This code involves biopsy of osseous lesions and is not used for apicoectomy/periradicular surgery. Excision of benign lesion up to 1.25 cm Excision of malignant lesion up to 1.25 cm Excision of malignant tumor - lesion diameter up to 1.25 cm Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm Destruction of lesion(s) by physical or chemical method, by report; Examples include using cryo, laser or electro surgery. Removal of lateral exostosis (maxilla or mandible) Removal of torus palatinus Page 4

5 HCPCS Code D7473 D7510 D7520 D7530 D7540 D7620 D7640 D7720 D7740 D7820 D7870 G0104 J0178 J2503 J2778 J3396 J7308 J9035 Description Removal of torus mandibularis Incision and drainage of abscess - intraoral soft tissue; Involves incision through mucosa, including periodontal origins. Incision and drainage of abscess - extraoral soft tissue; Involves incision through skin. Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Removal of reaction producing foreign bodies, musculoskeletal system; May include, but is not limited to, removal of splinters, pieces of wire, etc., from muscle and/or bone. Maxilla - closed reduction (teeth immobilized, if present); No incision required to reduce fracture. See D7610 if interosseous fixation is applied. Mandible - closed reduction (teeth immobilized, if present); No incision required to reduce fracture. See D7630 if interosseous fixation is applied. Maxilla - closed reduction Mandible - closed reduction Closed reduction of dislocation; Joint manipulated into place; no surgical exposure. Arthrocentesis; Withdrawal of fluid from a joint space by aspiration. Colorectal cancer screening; flexible sigmoidoscopy Injection, aflibercept, 1 mg Injection, pegaptanib sodium, 0.3 mg Injection, ranibizumab, 0.1 mg Injection, verteporfin, 0.1 mg Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg) Injection, bevacizumab, 10 mg IX. REFERENCES N/A X. POLICY HISTORY MP CAC 11/25/14 - New policy. Coding reviewed. Admin 10/1/15 - Cross-references were updated. CAC 11/24/15 - Consensus review. No changes to the policy statements. Coding reviewed; end dated codes removed. Administrative 6/24/16 Procedure code C9257 added (J9035 on policy) Admin update 12/5/16: Product variation section reformatted. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 5

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