CurrentColorado Rocky Mountain Health PlansPolicy CS143.T

Outpatient Surgical Procedures – Site of Service – Community Plan Medical Policyopen_in_new

Defines medical necessity criteria for performing planned outpatient surgical procedures in a hospital outpatient department rather than an ambulatory surgical center (ASC), lists clinical conditions and access limitations that justify hospital outpatient site of service, and references state-specific applicability and prior authorization list.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Surgical Procedures – Site of Service – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS143.T

Change TypeTemplate updateDocumentation guidance added

Effective DateAug 1, 2025

Next Review Date

Key ActionSite of service medical necessity reviews will be conducted for certain surgical procedures when performed in an outpatient hospital setting; providers must refer to the UnitedHealthcare Community Plan Prior Authorization List for the complete list of procedure codes requiring prior authorization.

SourceLink

POLICY UPDATE CHANGES

04/01/2026 - Template Update removed content/language pertaining to the state of Louisiana.

08/01/2025 - Added Medical Records Documentation Used for Reviews language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required.

>=1Site-of-service clinical criteria groups

MultipleClinical conditions listed

State-specific

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Policies excluded/applicable by state

Coverage summary

This policy (Policy Number: CS143.T, effective August 1, 2025, last reviewed April 1, 2026) defines medical necessity criteria for when planned outpatient surgical procedures should be performed in a hospital outpatient department rather than an ambulatory surgical center (ASC). It applies to UnitedHealthcare members and their providers and describes clinical conditions and access limitations that justify hospital outpatient site of service. The policy is implemented through site-of-service medical necessity reviews and ties to state- or contract-specific applicability and prior authorization requirements.

The policy's aim is to ensure appropriate site selection based on documented patient clinical risk factors or lack of ASC access, and to align coverage decisions with applicable federal, state, or contractual requirements and internal prior authorization processes.

Key thresholds and scope

MELD score threshold> 8

COPD (FEV1) thresholdFEV1 < 50%

Poorly controlled asthma (FEV1) thresholdFEV1 < 80% despite medical management

Recent CVA/TIA windowEvent < 3 months

Recent MI windowEvent < 3 months

DES/BMS/angioplasty timingDES within 1 year; BMS or plain angioplasty within 90 days (exception if antiplatelet therapy continued by agreement)

Prolonged surgery duration> 3 hours

OSA severity thresholdsModerate: AHI/RDI ≥15 and ≤30; Severe: AHI/RDI >30/hr

Scope summaryDefines clinical criteria and access limitations that make hospital outpatient department medically necessary instead of ASC; lists specific thresholds and conditions

State-specific applicability notePolicy does not apply to certain states; follow state-specific policy/guideline where noted (e.g., Idaho, New Jersey, North Carolina, Ohio, Pennsylvania, Tennessee)

Medical necessity: clinical risk and ASC access

Medically necessary reasons for hospital outpatient department site of service

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary when ANY of the following clinical conditions are present:

ANY of the following

Advanced liver disease (MELD Score > 8)MELD Score > 8
Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Anticipated need for transfusion
Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect

Prior authorization, documentation, and billing rules

Prior Authorization

Site of service medical necessity review and prior authorization

Site-of-service reviews and prior authorization apply for certain outpatient surgical procedures performed in a hospital outpatient setting. Providers must consult the UnitedHealthcare Community Plan Prior Authorization List for the complete list of surgical procedure codes that require prior authorization.

See Prior Authorization List — procedure codes

Documentation Required

Medical records documentation may be required

Medical records documentation may be requested to determine whether the member meets the clinical criteria for coverage and to support site-of-service decisions. Documentation of medical records does not guarantee that the requested service will be covered; coverage is determined by federal, state, or contractual requirements and applicable laws.

Codes and prior authorization list

Prior authorization required/Planned surgical procedures listmixed

No codes listed

Background and definitions

Purpose: To provide guidance on when certain planned outpatient surgical procedures should be performed in a hospital outpatient department because of specific clinical risk factors or inability to access an ASC. The policy supports site-of-service medical necessity reviews, references the UnitedHealthcare Community Plan Prior Authorization List for procedures requiring prior authorization, and clarifies that benefit coverage is governed by federal, state, or contractual requirements; medical records may be requested to assess criteria but do not guarantee coverage.

References and external guidance: The policy references and aligns with external professional guidance (for example, ASA and AASM statements and definitions) and acknowledges that federal, state, or contractual requirements supersede this policy where applicable. It also notes exclusions and state-specific policies where the policy does not apply.

ASA Physical Status Classification System: The American Society of Anesthesiologists’ subjective five-class system to categorize a patient's physiological status and help predict operative risk.

Obstructive Sleep Apnea (OSA): As defined by the American Academy of Sleep Medicine, a sleep-related breathing disorder with severity categorized by AHI/RDI: Mild: AHI/RDI ≥ 5 and < 15; Moderate: AHI/RDI ≥ 15 and ≤ 30; Severe: AHI/RDI > 30/hr.

Poorly Controlled (hypertension): Defined as requiring three or more drugs to control blood pressure.

Revision history

2025-08-01non-material

Added Medical Records Documentation Used for Reviews language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required.

2026-04-01administrativeLatest

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

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Surgical Procedures – Site of Service – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS143.T

Change TypeTemplate updateDocumentation guidance added

Effective DateAug 1, 2025

Next Review Date

SourceLink

On This Page

Cardiac arrhythmia (symptomatic arrhythmia despite medication)

Chronic obstructive pulmonary disease (COPD)FEV1 < 50%

FEV1 < 50%

Coronary artery disease (CAD)/peripheral vascular disease (PVD) [ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stent]DES within 1 year

Developmental stage or cognitive status warranting use of a hospital outpatient department

End stage renal disease [(hyperkalemia above reference range) receiving peritoneal or hemodialysis]

History of cerebrovascular accident (CVA) or transient ischemic attack (TIA)event < 3 months

recent event (< 3 months)

History of myocardial infarction (MI)event < 3 months

recent event (< 3 months)

Individuals with drug eluting stents (DES) placed within one year or bare metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesiaDES within 1 year; BMS/plain angioplasty within 90 days

Exception if acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesia

Ongoing evidence of myocardial ischemia

Poorly Controlled asthmaFEV1 < 80% despite medical management

FEV1 < 80% despite medical management

Prolonged surgery> 3 hours

Prolonged surgery (> 3 hours)

Resistant hypertension (Poorly Controlled)

Severe valvular heart disease

Sleep apnea [moderate to severe Obstructive Sleep Apnea (OSA)]Moderate: AHI/RDI ≥15 and ≤30; Severe: AHI/RDI >30/hr

Moderate: AHI/RDI ≥15 and ≤30; Severe: AHI/RDI >30/hr

Uncompensated chronic heart failure (CHF) (NYHA class III or IV)NYHA class III or IV

NYHA class III or IV

Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia

Under 18 years of age, unless otherwise required by federal, state, or contractual requirements

Medically necessary reasons for hospital outpatient department due to inability to access ASC

A planned surgical procedure is considered medically necessary in a hospital outpatient department if there is inability to access an ASC for ANY one of the following reasons:

ANY of the following

An ASC's specific guideline regarding the individual's health conditions or weight that would preclude management of an individual within an ASC setting
There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure (examples: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes such as duodenoscope, ureteroscope)
Excludes surgeon-preferred or proprietary instruments, instrument sets, or hardware sets
There is no geographically accessible ambulatory surgical center available at which the individual's physician has privileges

Billing Rule

State-specific applicability

This policy does not apply in certain states; providers must follow the applicable state-specific policy or guideline where noted.

Idaho
New Jersey
North Carolina
Ohio
Pennsylvania
Tennessee
Indiana
Kansas
Kentucky
Nebraska
New Mexico