MSK Codes Being Added to Site of Care Policy on May 1

Beginning May 1, 2026, 113 musculoskeletal (MSK) surgical procedure codes are being added to Highmark’s site of care clinical review requirements. The addition of these MSK codes was previously announced in the February Medical Policy Update and can be found in the following updated medical policies – Medical Policy Z-109 (Commercial) and Medical Policy Z-129 (Medicare Advantage).

This change is part of Highmark’s Site of Care Program to improve efficiency and patient outcomes by encouraging utilization of freestanding Ambulatory Surgery Centers (ASCs) or office-based settings for certain low-risk outpatient services.

While Highmark strongly encourages the utilization of ASCs or office-based settings for eligible procedures, we recognize that certain clinical situations may necessitate a hospital outpatient setting. Providers may perform the procedures in a hospital outpatient department setting under specific criteria set forth in the medical policies, including:

• Patient complexity and comorbid conditions
• Geographic limitations (e.g., access to ASCs in rural areas)
• Clinical judgment and other factors

Submitting Authorizations

Site of care clinical review requirements will apply to Highmark fully insured Commercial, Affordable Care Act (ACA), and Medicare Advantage (MA) members. Please confirm member benefits to ensure in-network site of care requirements apply.

As a reminder, the management of MSK and interventional pain management (IPM) services is moving from eviCore to Highmark, also beginning May 1, 2026. Authorization for these codes will now be reviewed by Highmark and must be submitted to us through the Availity Essentials portal beginning May 1. Submitting electronically leads to faster reviews and response times.

If you do not currently use Availity for other payers, go to Register and Get Started with Availity Essentials.