Automatic Approvals for Individual Plans in Ambulatory Surgery Centers

As of January 1, 2025, providers who submit prior authorizations for patients with individual plans will receive automatic approvals for specific procedure codes when performed in ambulatory surgery centers. If the service is performed at any other location, the standard process applies: Prior authorization is required, and medical necessity is reviewed using InterQual criteria.

This change aims to streamline the approval process for certain procedures, reducing administrative tasks, and improving efficiency for providers. The automatic approval applies only to the following procedure codes:

• 38525: Biopsy or excision of lymph node(s); open, deep axillary node(s)
• 49650: Laparoscopy, surgical; repair initial inguinal hernia
• 58558: Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
• 58662: Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
• 30520: Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
• 30140: Submucous resection inferior turbinate, partial or complete, any method
• 57425: Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
• 64718: Neuroplasty and/or transposition; ulnar nerve at elbow