CurrentColorado Rocky Mountain Health PlansPolicy CS182.J

Elective Inpatient Services – Community Plan Medical Policy

Defines clinical criteria when a planned elective inpatient admission for surgeries or procedures is considered medically necessary, using InterQual® criteria and specific patient-, procedure-, and event-related risk factors. Excludes obstetric care and states with separate policies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElective Inpatient Services – Community Plan Medical Policy

Policy CodePolicy CS182.J

Change TypeDefinitions and template updates (no material clinical change)

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must document the presence of any listed medical conditions, procedure-related risk factors, advance planning considerations, or procedural events that justify inpatient admission per the policy and InterQual® criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — definitions/supporting info and template wording updated without changing clinical policy.

MultipleCovered Indications

11States with separate policies

1Policy Version Suffix

Coverage Summary

Key clinical thresholds

MELD Score> 8

GFR≤ 30 mL/min

Stroke/TIA timeframeWithin last 3 months

Age≥ 85 years

AHI (Apnea Hypopnea Index)Moderate 15-30; Severe > 30

Acute Kidney Injury criteriaIncrease in serum creatinine ≥ 0.3 mg/dL in 48 hours OR ≥1.5× baseline within 7 days OR >50% reduction in eGFR OR urine <0.5 mL/kg/hr for 6 hours

Hemodynamic Instability criteriaSBP <90 mm Hg or decrease >40 mm Hg; oliguria goal 0.5 mL/kg/hr; MAP <65 mm Hg; capillary refill >3 sec; altered LOC; shortness of breath; persistent tachycardia

Medically Necessary Elective Inpatient Admission Criteria

A planned elective inpatient admission for certain surgeries or procedures is considered medically necessary when ANY of the following criteria are met:

ANY of the following

Medical conditions increasing the risk of major post-operative complications
- Advanced liver disease (MELD Score > 8)> 8
- Cognitive status that warrants inpatient stay
- Severe renal disease (GFR ≤ 30 mL/min)≤ 30 mL/min
- Severe valvular heart disease
- Stroke or TIA within last 3 monthswithin last 3 months
- Symptomatic chronic lung disease (e.g., asthma, COPD)
- Symptomatic coronary artery disease or heart failure
- Unstable medical condition (e.g., poorly controlled diabetes)
Procedure-related factors that may increase the risk of complications
- Anesthetic risk: American Society of Anesthesiologists class III or greaterASA III or greater
  See ASA Physical Status Classification
- Age 85 years or older≥ 85 years
- High risk for thromboembolism
- Moderate (AHI 15-30) to severe (AHI > 30) sleep apneaAHI Moderate 15-30; Severe > 30
  See AHI definition
Advance surgical planning determines an individual requires inpatient recovery and care following a surgical procedure
- Individual's residence is distant to medical facility and there is a potential for urgent complications and no other nearby temporary residence is available and not appropriate for ambulatory or observation level of care
- Pre- or post-operative inpatient monitoring or treatment related to need to discontinue drugs or other therapies
Procedural related event that may require an inpatient stay
- Acute Kidney InjurySee AKI definition
  KDIGO 2012 criteria
- Altered mental status that is severe or persistent
- Ambulatory or appropriate activity level status is not achieved
- Conversion to open or complex procedure that requires inpatient care
- Excessive drainage or bleeding from the operative site
- Hemodynamic Instability

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Policy Applicability Exceptions

Policy Applicability Exceptions (States with separate policies)mixed

States

Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee - refer to state-specific Elective Inpatient Services policy

The listed states (Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee) refer to state-specific Elective Inpatient Services policies and are excluded from the application of this policy; consult the named state-specific policy/guideline for those members.

Provider Actions and Requirements

Documentation Required

Document risk factors and rationale for inpatient admission

Providers must document the presence of any listed medical conditions, procedure-related risk factors, advance planning considerations, or procedural events that justify inpatient admission per the policy and InterQual® criteria.

Prior Authorization

Use InterQual® criteria for medical necessity decisions

UnitedHealthcare uses InterQual® as a source to support medical necessity and level-of-care decisions; providers should expect review against InterQual® and submit supporting clinical information.

Providers should submit supporting clinical information for review against InterQual®.