CurrentAetnaPolicy 0255

Inpatient Admission Prior to Surgery (Preop Days)

Policy Summary

PayerAetna

PolicyInpatient Admission Prior to Surgery (Preop Days)

Policy CodePolicy 0255

Change TypeRevised (no material clinical changes)

Effective DateMay 26, 1998

Next Review DateMar 14, 2024

Key ActionDocument that one or more listed medical necessity criteria are met to justify preoperative inpatient admission.

SourceLink

POLICY UPDATE CHANGES

Last review date noted as 04/26/2023 with next review 03/14/2024; effective date 05/26/1998.

11Listed medical necessity scenarios

CURRENTPolicy status

Coverage Summary

Defines medical necessity criteria under which inpatient hospital admission on days prior to surgery (preoperative days) is considered medically necessary by Aetna, including specific clinical scenarios (e.g., IV fluids for infants, extensive bowel preparation with high-risk comorbidity, brittle insulin-dependent diabetes needing close glucose monitoring, conversion from coumadin to IV heparin, IV steroid/anticonvulsant/osmotic diuresis preparations, placement of fiducials, concurrent medical problems requiring inpatient treatment) and that transplant candidate hospitalizations are assessed by the same criteria. Coverage stance: covered_with_criteria. Effective date: 05/26/1998; Last review: 04/26/2023; Next review: 03/14/2024.

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Medical-Necessity Criteria

Medical Necessity for Inpatient Admission Prior to Surgery

Aetna considers inpatient hospital admission on days prior to surgery medically necessary when ANY of the following criteria is met:

ANY of the following

A cardiac catheterization or a major surgical procedure scheduled within 24 hours for a child less than 1 year of age which requires intravenous fluids to achieve and maintain adequate hydration prior to the procedure.Age for cardiac catheterization/major surgery hydration indication: < 1 year; Timing: within 24 hours
A planned major surgical procedure which requires an extensive bowel preparation (GoLytely, laxatives, multiple enemas) in a member with a co-morbidity whose condition places the individual at high-risk for electrolyte and fluid imbalances (example co-morbidities: chronic renal failure, elderly individual with muscle wasting and poor nutritional status resulting in a significant weight loss of greater than 10%).Significant weight loss for high-risk bowel prep: > 10 %
A planned surgical procedure on partially obstructed bowel which requires a slow but extensive bowel preparation pre-operatively.
An invasive diagnostic procedure (e.g., aortogram, arteriogram or cardiac catheterization, myelogram) with major surgery scheduled for the following day.
Close monitoring of blood sugars is required to provide adequate adjustment of regular insulin coverage in preparation for an operative procedure in a brittle insulin-dependent diabetic member (i.e., diabetic individuals who experience large, unpredictable changes in blood glucose, within short periods of time, as a result of very small deviations from schedule).
Placement of fiducials (small screws) prior to stereotactic brain surgery.
The member has a concurrent medical problem that requires specific inpatient treatment prior to major surgery (defined as craniotomy, laparotomy, median sternotomy, or thoracotomy) to reduce the operative risk or assure a more favorable outcome.
The member is scheduled for an open heart procedure requiring cardiopulmonary bypass (cardiac valve replacement or repair, coronary artery bypass grafting) and has unstable angina, congestive heart failure, severe hypertension, or significant ventricular arrhythmias.
The member requires conversion from coumadin to intravenous heparin (not subcutaneous heparin) for a surgical procedure planned for the next day. (Note: individuals with mitral valve disease, especially with atrial fibrillation, may require 2 pre-operative days.)
The member requires intravenous steroid preparation for protection against a previously documented allergic reaction to dye prior to intravascular administration of dye necessary to perform a diagnostic study or operative procedure.
The member requires intravenous steroid preparation, intravenous anti-convulsant protection, or osmotic diuresis prior to a craniotomy scheduled for the following day (e.g., intracranial arteriovenous malformations).
Hospitalization prior to transplant: hospitalization of members awaiting transplant is considered medically necessary only when the member has needs that justify inpatient confinement; assessment uses the same criteria as for other conditions.
Assessment uses the same criteria as for other conditions.

Provider Actions

Documentation Required

Document clinical justification for preoperative inpatient admission

Providers must document that one or more of the listed medical necessity criteria are met when requesting inpatient admission prior to surgery. Examples that should be documented include:

Need for IV fluids in an infant undergoing cardiac catheterization or major surgery scheduled within 24 hours
Extensive bowel preparation (e.g., GoLytely, laxatives, multiple enemas) in a member with a high-risk comorbidity (e.g., chronic renal failure, significant weight loss >10%)
Brittle insulin-dependent diabetes requiring close glucose monitoring and insulin adjustment
Need for conversion from coumadin to intravenous heparin prior to surgery
Intravenous steroid preparation, intravenous anticonvulsant protection, or osmotic diuresis prior to craniotomy
Concurrent medical problems requiring specific inpatient treatment prior to major surgery

Prior Authorization

Prior authorization may be required per plan rules

Prior authorization processes of the member's plan may apply to inpatient admissions prior to surgery. When prior authorization is required, authorization reviewers will use this clinical policy's criteria to assess whether the inpatient preoperative admission is medically necessary.

Authorization reviewers will apply the policy's listed medical necessity criteria when assessing preoperative inpatient admissions.

Background and Evidence

Policy provides criteria for when inpatient hospitalization prior to surgery is medically necessary, including specific perioperative preparations such as intravenous fluids, extensive bowel preparation (GoLytely, laxatives, multiple enemas), intravenous steroid preparation, intravenous anticonvulsant protection, and osmotic diuresis 10% weight loss) that increase risk for electrolyte and fluid imbalances, and notes that hospitalization prior to transplant is considered medically necessary only when inpatient confinement is justified using the same criteria. Related policies include warfarin-to-heparin conversion guidance (CPB 0200).

References include the American Society of Anesthesiologists (ASA) Basic Standards for Preanesthesia Care (ASA; October 14, 1987) and multiple literature sources on perioperative management and same-day admission studies, for example: Arom KV et al., Patient characteristics, safety, and benefits of same-day admission for coronary artery bypass grafting (Ann Thorac Surg. 1996); Bach DS, Management of specific medical conditions in the perioperative period (Prog Cardiovasc Dis. 1998); and other cited works on antithrombotic therapy, perioperative medication management, renal perioperative care, preoperative evaluation, preoperative cardiac evaluation, and diabetes management in surgical patients.

Definitions

Explicit thresholds

OpenPayer

Inpatient Admission Prior to Surgery (Preop Days)

Coverage Summary

Medical-Necessity Criteria

Provider Actions

Related Codes

Background and Evidence

Revision History