CurrentColorado Rocky Mountain Health PlansPolicy CS182.J

Elective Inpatient Services

Defines medical necessity criteria for planned elective inpatient admissions following surgeries or procedures, listing patient medical risk factors, procedure-related risk factors, and postoperative events that justify inpatient status. Excludes applicability to obstetric members and lists state-specific exceptions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElective Inpatient Services

Policy CodePolicy CS182.J

Change TypeDefinitions and template updates

Effective DateFebruary 1, 2026

Next Review Date

Key ActionUse InterQual criteria to support medical necessity and level-of-care decisions and document the specific qualifying medical condition, procedural risk factors, or postoperative events that justify inpatient admission.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and supporting information/clinical evidence and references.

Template Update removed content/language pertaining to the state of Louisiana.

MultipleQualifying risk factor categories

11State-specific policy exceptions listed

1Policy document

Coverage Summary

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Overview: This policy (Policy Number CS182.J) addresses coverage for elective inpatient admissions following planned surgeries or procedures and is classified as covered_with_criteria. Effective date: February 1, 2026; Last review: February 1, 2026. The policy specifies clinically necessary criteria to justify elective inpatient status (see medical conditions, procedure-related factors, and postoperative events) and directs use of specified criteria and documentation to support medical necessity.

Surface thresholds

MELD Score> 8

GFR≤ 30 mL/min

Stroke/TIA timeframewithin last 3 months

Age>= 85 years

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

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

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

Medically Necessary: Elective Inpatient Admission Criteria

Medically necessary elective inpatient admission

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

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Exclusion: This policy does not apply to an obstetric member during pregnancy, childbirth, or the post-partum period. The policy also lists state-specific exceptions where a different state policy/guideline applies (Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee).

Provider Actions & Documentation Requirements

Documentation Required

Document medical necessity using InterQual when applicable

Use InterQual criteria when applicable to support medical necessity and level-of-care decisions. Document the specific qualifying medical condition(s), any procedure‑related risk factors, or postoperative events that justify inpatient admission in the medical record so review can be correlated to InterQual findings.

Specify which listed medical condition(s) from the policy justify inpatient status (e.g., advanced liver disease MELD > 8, severe renal disease GFR ≤ 30 mL/min, symptomatic coronary disease, recent stroke/TIA, etc.).
Describe procedure-related risk factors (e.g., ASA class III or greater, age ≥ 85 years, complex surgical approach, high thromboembolism risk, moderate to severe OSA).
Note any postoperative events that require inpatient care (e.g., acute kidney injury, hemodynamic instability, excessive bleeding, conversion to open procedure).

Documentation Required

Document AKI per KDIGO criteria

When Acute Kidney Injury (AKI) is cited as the reason for inpatient admission, document exactly which KDIGO 2012 AKI criterion is met in the record. This should include the qualifying serum creatinine change, percentage reduction in eGFR, and/or urine output threshold as applicable.

Document an increase in serum creatinine ≥ 0.3 mg/dL within 48 hours, OR
Document serum creatinine ≥ 1.5 times baseline within the prior 7 days, OR
Document reduction of >50% in eGFR from baseline, OR
Document urine volume < 0.5 mL/kg/hour for 6 hours.

Denial Risk

Potential denial if criteria not met

Admission may be denied or deemed inappropriate if none of the listed medical conditions, procedure-related risk factors, or postoperative events that justify inpatient level of care are documented in the medical record. Ensure documentation ties the patient’s presentation to one or more specific criteria in the policy to avoid denial risk.

If AKI, specify which KDIGO threshold is met (see AKI definition).
If procedure-related risk, document the specific factor (e.g., ASA class, age, complexity, OSA severity).
If postoperative event, document the event (e.g., hemodynamic instability, excessive bleeding, conversion to open procedure).

Background & Evidence

Background: UnitedHealthcare uses InterQual criteria as an evidence source to support medical necessity and level-of-care decisions. The policy references multiple specialty guidelines to inform perioperative risk assessment, including the AHA/ACC perioperative cardiovascular guideline, the ASA Physical Status Classification System, the AASM definitions for sleep apnea, GINA guidance on asthma, and KDIGO criteria for Acute Kidney Injury. The policy explicitly excludes obstetric members during pregnancy, childbirth, and the post-partum period. InterQual is listed in the policy's evidence section as a source used to support medical necessity when applicable.

Label	Value
InterQual	Used as a source of medical evidence to support medical necessity and level-of-care decisions when applicable
KDIGO AKI criteria	AKI diagnostic thresholds included: increase in serum creatinine ≥ 0.3 mg/dL in 48 hours; or ≥ 1.5 times baseline within prior 7 days; or >50% reduction in eGFR from baseline; or urine volume < 0.5 mL/kg/hr for 6 hours (KDIGO, 2012).

Operational definitions referenced in criteria

Definitions

Acute Kidney Injury: Defined as increase in serum creatinine ≥ 0.3 mg/dL in 48 hours; or ≥ 1.5 times baseline within prior 7 days; or >50% reduction in eGFR from baseline; or urine volume < 0.5 mL/kg/hour for 6 hours (KDIGO, 2012).see AKI criteria
KDIGO 2012
Apnea Hypopnea Index (AHI): Number of apneas plus hypopneas during sleep period per hour; mild AHI ≥ 5 and < 15; moderate AHI ≥ 15 and ≤ 30; severe AHI > 30 events/hour (AASM, 2008).Mild 5-14; Moderate 15-30; Severe >30
AASM 2008
ASA Physical Status Classification: Six-class system to categorize pre-anesthesia physiological status; ASA III or greater considered increased anesthetic risk.ASA III or greater
ASA, 2020
Hemodynamic Instability: Vital sign abnormality not readily corrected by treatment as indicated by SBP < 90 mm Hg or decrease in SBP > 40 mm Hg; oliguria treatment goal 0.5 mL/kg/hour; MAP < 65 mm Hg; new abnormal capillary refill > 3 sec; altered level of consciousness; shortness of breath; persistent tachycardia.SBP <90 or decrease >40; MAP <65; urine output <0.5 mL/kg/hr; cap refill >3 sec
Sevransky, 2009

Revision History

2026-02-01last_review/effectiveLatest

Definitions and supporting information updated: Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and supporting information/clinical evidence and references. Change marked non‑material to clinical policy statements.

2026-04-01template_update/archival

Template update archived previous policy version CS182.I and removed content/language pertaining to the state of Louisiana. Change marked non‑material to clinical policy statements.