Effective January 1, 2023, UnitedHealthcare is conducting site of service medical necessity reviews for screening colonoscopies conducted in hospital-based outpatient departments (HOPDs) to determine whether utilization of an HOPD rather than an ambulatory surgery center (ASC) was medically necessary, in accordance with the terms of the member’s benefit plan. If the HOPD is not considered medically necessary, this location will not be covered under the member’s plan.
This policy may be problematic for members who are hospital-based and do not have credentials for an ASC. Valid reasons for HOPD selection are detailed in the policy, and members are encouraged to review them and consider their practice in light of them, paying particular attention to the following, which was excerpted from the policy document.
A planned preventive screening colonoscopy performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to any one of the following:
- There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure; (examples include but are not limited to: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes required to perform specialized procedures (i.e., duodenoscope, ureteroscope); or
- An ASC’s specific guideline regarding the individual’s weight or health conditions that prevents the use of an ASC
Read the policy.