UHC to conduct site-of-service reviews for screening colonoscopies

October 20, 2020
Area(s) of Interest: Payor Issues and Reimbursement 

Effective January 1, 2021, UnitedHealthcare (UHC) will implement a new policy restricting screening coloscopy procedures in the outpatient hospital setting for its commercial line of business. Under the new policy, UHC will conduct a site-of-service medical necessity review to determine whether usage of the outpatient hospital setting is medically necessary. Usage of the outpatient hospital setting for a screening colonoscopy will only be considered medically necessary for patients meeting any one of the following criteria:

  • Advanced liver disease (MELD Score > 8)
  • Anticipated need for transfusion
  • Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect
  • Brittle diabetes
  • Cardiac arrhythmia (symptomatic arrhythmia despite medication)
  • Chronic obstructive pulmonary disease (FEV1 < 3 months)
  • History of myocardial infarction (recent event [< 3 months])
  • Individuals with drug eluting stents placed within one year or bare metal stents  or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist and anesthesia
  • Ongoing evidence of myocardial ischemia
  • Poorly controlled asthma (FEV1 < 80% despite medical management)
  • Resistant hypertension (poorly controlled)
  • Severe valvular heart disease
  • Sleep apnea (moderate to severe obstructive sleep apnea
  • Uncompensated chronic heart failure (NYHA class III or IV)

Screening colonoscopy procedures to be performed at an ambulatory surgical center (ASC) will not be subject to the new site-of-service review policy. UHC will also consider the hospital outpatient department medically necessary for a screening colonoscopy 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; or
  • An ASC’s specific guideline regarding the individual’s weight or health conditions that prevents the use of an ASC.

For questions regarding the new policy, contact UHC Provider Services at (888) 478-4760.


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