Resources
Expansion to Surgical Site of Care coming November 1, 2026
Site of Care clinical guidelines will apply to additional Ear, Nose and Throat procedures and breast reduction procedures; specifically at outpatient hospital settings. Please see the applicable code list for CPT details and the guideline link for clinical information.
Surgical Clinical Review
- Surgical Procedures: Applicable Code List
- Surgical Appropriate Use Criteria: Site of Care
- Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy)
*Note: Procedures reviewed may vary by health plan
Order request checklists:
Wondering what information you’ll need to enter your order request? Download our checklist to learn more.
Questions?
For questions related to an order request for a specific patient, contact Carelon Medical Benefits Management at 866-789-1456 for further assistance.
Call the Carelon provider portal support team at 800-252-2021 for help using provider portal.
Clinical Guidelines:
View the clinical criteria that guides our review process
Upper Gastrointestinal Endoscopy
Cosmetic and Reconstructive Services: Skin Related
Autologous Adipose-derived Regenerative Cell Therapy
Surgical and Ablative Treatments for Chronic Headaches
Products for Wound Healing and Soft Tissue Grafting: Investigational
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Panniculectomy and Abdominoplasty
Reduction Mammaplasty
Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
Mastectomy for Gynecomastia
Temporomandibular Disorders
Mandibular Maxillary (Orthognathic) Surgery
Internal Rib Fixation Systems
Extracorporeal shockwave therapy
Nasal Valve Repair
Septoplasty
Functional Endoscopic Sinus Surgery (FESS)
Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
Balloon Sinus Ostial Dilation
Bronchial Thermoplasty
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Implantable infusion pumps
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
Ablative Techniques as a Treatment for Barrett’s Esophagus
Paraesophageal Hernia Repair
Lower Esophageal Sphincter Augmentation Devices
Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Doppler-Guided Transanal Hemorrhoidal Dearterialization
Treatments for Urinary Incontinence
Penile Prosthesis Implantation
Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
Ultrasound Ablation for Oncologic Indications
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Vagus Nerve Stimulation
Canaloplasty
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Implanted Artificial Iris Devices
Implanted Port Delivery Systems to Treat Ocular Disease
Balloon Dilation of the Eustachian Tubes
Bone-Anchored and Bone Conduction Hearing Aids
Cochlear Implants and Auditory Brainstem Implants
Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Automated Evacuation of Meibomian Gland
Renal Sympathetic Nerve Ablation
Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Corneal Collagen Cross-Linking
Irreversible Electroporation
Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
Drug-Eluting Devices for Maintaining Sinus Ostial Patency
Implantable Middle Ear Hearing Aids
Presbyopia and Astigmatism-Correcting Intraocular Lenses
Clinical Guidelines:
View the clinical criteria that guides our review process
Upper Gastrointestinal Endoscopy
Site of Care for Surgical Procedures
Clinical Guidelines:
View the clinical criteria that guides our review process
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Upper Gastrointestinal Endoscopy
Site of Care for Surgical Procedures
Cosmetic and Reconstructive Services: Skin Related
Autologous Adipose-derived Regenerative Cell Therapy
Surgical and Ablative Treatments for Chronic Headaches
Products for Wound Healing and Soft Tissue Grafting: Investigational
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Panniculectomy and Abdominoplasty
Reduction Mammaplasty
Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
Mastectomy for Gynecomastia
Temporomandibular Disorders
Mandibular Maxillary (Orthognathic) Surgery
Internal Rib Fixation Systems
Extracorporeal shockwave therapy
Nasal Valve Repair
Septoplasty
Functional Endoscopic Sinus Surgery (FESS)
Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
Balloon Sinus Ostial Dilation
Bronchial Thermoplasty
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Implantable infusion pumps
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
Ablative Techniques as a Treatment for Barrett’s Esophagus
Paraesophageal Hernia Repair
Lower Esophageal Sphincter Augmentation Devices
Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Doppler-Guided Transanal Hemorrhoidal Dearterialization
Treatments for Urinary Incontinence
Penile Prosthesis Implantation
Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
Ultrasound Ablation for Oncologic Indications
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Vagus Nerve Stimulation
Canaloplasty
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Implanted Artificial Iris Devices
Implanted Port Delivery Systems to Treat Ocular Disease
Balloon Dilation of the Eustachian Tubes
Bone-Anchored and Bone Conduction Hearing Aids
Cochlear Implants and Auditory Brainstem Implants
Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Automated Evacuation of Meibomian Gland
Renal Sympathetic Nerve Ablation
Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Corneal Collagen Cross-Linking
Irreversible Electroporation
Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
Drug-Eluting Devices for Maintaining Sinus Ostial Patency
Implantable Middle Ear Hearing Aids
Presbyopia and Astigmatism-Correcting Intraocular Lenses