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Outpatient Procedures

We require the following services to be delivered in an office or outpatient setting. If performed inpatient, Preauthorization is required. This list does not contain procedures generally recognized as office/outpatient, or changed to these settings by established provider community practices. Medicare requires some of these procedures to be performed in an inpatient setting.

Procedure Limitations & Notes
Acromioplasty, Shoulder; Open  
Adenoidectomy, Obstructive Adenoid Hypertrophy
  • Only applies to pediatric patients under age 3
Angioplasty, Non-Cardiac; Endovascular Intervention
  1. Mesenteric/ Celiac Artery
  2. Peripheral Artery
  3. Renovascular (Percutaneous Balloon)
  4. Transluminal balloon angioplasty, open, renal artery; aortic, iliac, and fem/pop
Appendectomy; Laparoscopic
  • A community practice since 2000
Arterial Ligation  
Arthroscopically-assisted surgery; Knee  
Automatic Implantable Cardio Defibrillator, Single Chamber (AICD) Insertion and Removal; Elective, Transvenous (Excludes dual-chamber, urgent, and thoracotomy insertion approach)  
Baker’s Cyst Removal  
Bariatric Surgery; Laparoscopic Gastric Banding
Bone Graft, Fracture Malunion or Nonunion, Long Bones: Humerus, Radius, Ulna  
Breast Reconstruction
Breast Reduction Surgery; including surgery for Gynecomastia
Cervical Cerclage (McDonald/ Shirodkar)  
Chemonucleolysis, Nucleus Pulposis  
Cholangiography; Percutaneous Transhepatic  
Cholecystectomy; Laparoscopic (Uncomplicated)
  • A community practice since 2000
Chondroplasty, Ankle; Open  
Cleft Lip Repair  
Cerebrospinal Fluid Shunt Insertion/Revision/Removal/Replacement  
Cystectomy, Ovarian; Simple, Laparoscopic  
Cystoplasty/ Cystourethroplasty, including Vesicourethropexy + Pubovaginal Sling (excludes Augmentation Cystoplasty)  
Decompression, Subacromial space, Shoulder; Open  
Digital Artery Repair, Hand, Microsurgical  
Dilatation & Curettage, and/or Evacuation  
Disarticulation: Wrist  
Discectomy TMJ
  • A community practice since 2000
Drainage; Renal Abscess, Percutaneous  
Ectopic Pregnancy; Laparoscopic  
Electrophysiology Testing without Ablation  
Endovascular Intervention, Peripheral Artery, Intracranial: Unruptured Aneurysm  
Excision, Melanoma  
Excision, Vulvar Lesion; Simple  
Facial Nerve Repair  
Gastrostomy/Jejunostomy; Laparoscopic, Open  
Hardware Removal, Open; Ankle, Elbow, Shoulder  
Heel Cord Lengthening  
Herniorraphy; Laparoscopic, Open:
  • Femoral
  • Inguinal
  • Umbilical
  • Ventral
Hysterorrhaphy; Laparoscopic  
Incision and Drainage, Infection  
Intussusception; Reduction
  • A community practice since 2000
  • Only applies to pediatric patients
Laparotomy, Mini  
Laparoscopy, Diagnostic; Abdomen  
Lavage, Arthroscopic for Joint Infection: Ankle, Elbow, Hip, Knee, Shoulder, Wrist
  • A community practice since 2000
Lithotripsy, Extracorporeal Shockwave; Ureteral, Renal  
Lysis of Adhesions, Gastrointestinal; Laparoscopic  
Mastoidectomy with or w/out Tympanoplasty  
Meckel’s Diverticulum Excision; Laparoscopic  
Nasal/ Sinus Endoscopic Surgery without CSF Leak  
Orchiectomy; Scrotal or Inguinal  
Pacemaker Insertion; Single Ventricular (excludes dual-ventricular, urgent, and thoracotomy insertion approach)  
Pacemaker Reprogramming, Non-Urgent  
Patellar Fracture Repair  
Patellar Tendon Rupture Repair  
Prostate: Transurethral; Laser Coagulation of Prostate, Laser Vaporization of Prostate  
Radiofrequency Ablation (RFA), Liver; Laparoscopic  
Reconstruction, Knee; Arthroscopically-Assisted, Open
  • A community practice since 2000
Release, Contracture, Open; Ankle, Knee, Hip
  • A community practice since 2000
Release, Hip Flexor/ Adductor  
Repair AC Separation (AC Ligament), Shoulder
  • A community practice since 2000
Repair Achilles Tendon; Complete Tear  
Repair Acute Ligamentous Injury, Knee  
Repair Acute and Chronic Rotator Cuff/ Capsule Tear, Shoulder; Open  
Repair Annular Ligament Tear, Elbow
  • A community practice since 2000
Repair Deltoid Ligament, Ankle  
Repair Irreducible Dislocation, Shoulder  
Repair Meniscus, Knee; Open & Arthroscopic  
Resection, Distal Clavicle, Shoulder; Open  
Spine Procedure: Decompression Procedures, Single leve
Spine Procedure: Hemilaminectomy, with or w/out Foraminotomy; Lumbar, Single Level  
Spine Procedure: Laminectomy, Single level, with or w/out Discectomy
Spine Procedure: Vertebroplasty; Percutaneous
Submandibular Gland Excision  
Sympathectomy, Endoscopic  
Tonsillectomy with or w/out Adenoidectomy
  • Only applies to pediatric patients under age 3
Trachelectomy: Laparoscopic  
Thrombolysis; Vascular Access Device  
  • Only applies to pediatric patients
Uterine Artery Embolization (UAE)  
Ureteroscopy with Stone Manipulation or Laser Lithotripsy  
Urethral Repair  
Urethroplasty: Epispadias/Hypospadias  
Valvuloplasty, Cardiac  
Varicose Vein Treatment Procedures (including but not limited to: Vein Ligation, Sclerosing Injection, VNUS and Laser procedures)
Wedge Resection; Ovary