WAC 296-23B-0120   What procedures are covered in an ambulatory surgery center?  The department will use the Centers for Medicare and Medicaid Services (CMS) list of procedures covered in an ambulatory surgery center plus additional procedures as determined by the department. All procedures covered in an ambulatory surgery center are listed in the Medical Aid Rules and Fee Schedules, Ambulatory Surgery Center Payment Policies section. Certain procedures are still subject to the utilization review program. Procedures that are not listed are not covered in an ambulatory surgery center.

     Under certain conditions, the director, the director's designee, or self-insurer, in their sole discretion, may determine that a procedure not on the list may be authorized in an ambulatory surgery center. For example, if the procedure could be harmful to a particular patient unless performed in an ambulatory surgery center. Requests for coverage under these special circumstances require prior authorization. The process for requesting coverage is outlined in the Medical Aid Rules and Fee Schedules, Ambulatory Surgery Center Payment Policies section.

     The department will allow some procedures to be covered in an outpatient setting that CMS covers only in an inpatient setting. The department will cover these procedures in an ambulatory surgery center if the following criteria are met:

     (1) The surgeon deems that it is safe and appropriate to perform such a procedure in an outpatient setting; and

     (2) The procedure meets the department's utilization review requirements.

Notes:	For information on the utilization review program please see the following:
	WAC 296-20-024 for utilization management authority.
	WAC 296-20-01002 for definition of utilization review.
	WAC 296-20-02700 through 296-20-03002 for medical coverage policies.
	Provider bulletins describing the utilization review program.
	These may be viewed online at www.lni.wa.gov.

[Statutory Authority: RCW 51.36.080, 51.04.030, 51.36.010, 51.04.020. 01-21-140, § 296-23B-0120, filed 10/24/01, effective 1/1/02.]