CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Elective Surgical Procedures

Defines Kaiser Permanente's clinical review criteria to determine the appropriate level of care (hospital inpatient vs hospital outpatient/observation vs ASC) for a broad set of elective surgical procedures and lists procedure code groupings that require review when submitted as inpatient. Applies to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Elective Surgical Procedures

Policy CodePolicy N/A

Change TypeRevised (historical updates 2022–2025)

Effective Date

Next Review DateFeb 1, 2026

Key ActionPrior authorization is required for the site of service for the listed elective surgical procedures; hospital-based outpatient is the default preferred authorization status and ASC diversion may be applied per ASC Site of Care Policy.

SourceLink

POLICY UPDATE CHANGES

Multiple revision history entries recorded including additions to policy scope and code updates between 2022 and 2025.

18Procedure categories listed

MultipleCodes requiring medical necessity review

SeveralMedicare inpatient-only codes (annotated X)

Includes HCPCSHCPCS/Drug/Supply codes present

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~350CPT codes enumerated (approx.)

Coverage Summary & Scope

Background: This policy guides level-of-care determinations for elective surgical procedures to encourage safe, appropriate, and cost‑effective site-of-service selection. It designates hospital-based outpatient as the default/preferred setting for listed elective procedures and requires prior authorization for the site of service.

Scope summary: Applies to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.; the policy defines clinical review criteria to determine the appropriate level of care (hospital inpatient vs hospital outpatient/observation vs ASC) for a broad set of elective surgical procedures and lists procedure code groupings that require review when submitted as inpatient, with hospital outpatient as the default authorization status and prior authorization required for site of service.

Key thresholds and policy status

Threshold: MELD ScoreMELD Score > 8

Threshold: Renal functionGFR < 30 mL/min

Threshold: AgeAge >= 85 years

Default site of serviceHospital outpatient (preferred)

Prior authorizationRequired for site of service

Medicare IP-only handlingExcluded — Medicare inpatient-only procedures annotated 'X' are not covered by this LOC policy

Next review date2026-02-01

Policy statusCURRENT (hospital-based outpatient is default)

Medical Necessity Criteria for Inpatient Level of Care

General criteria for inpatient level of care for planned elective admissions

Planned elective admissions for inpatient level of care are considered medically necessary when ANY of the following patient- or procedure-related criteria are present. (See Definitions: Acute Kidney Injury (AKI) — cross-reference in leaf notes.)

ANY of the following

Advanced liver disease (MELD score > 8)
Clinical scoring should be documented in records.
Acute Kidney Injury
See Definitions: AKI for diagnostic criteria and staging; include baseline creatinine and trend.
Medical conditions increasing the risk of major post-operative complications (e.g., severe cardiac, pulmonary, or systemic disease)
Include specific diagnosis, severity, and supporting diagnostics.

Code Groups and Review Annotations

Per-code flags used in the tables below: "Medicare IP Only (X)" indicates codes that are considered inpatient-only for Medicare members and therefore are excluded from applicability under this policy's ambulatory/observation default; "Requires ASC SOC Review" indicates the Ambulatory Surgery Center Site-of-Care policy should be consulted for potential redirection from hospital setting; and "Requires Medical Necessity Review" indicates the code/procedure may also require an independent medical necessity review in addition to level-of-care determination. Medicare IP-only codes are not considered by this policy for outpatient/ASC authorization and are therefore excluded from the policy's outpatient/ASC applicability.

Cardiac Procedure codesCPT

92928	Percutaneous transluminal revascularization of acute total/subtotal coronary occlusion (includes angioplasty when performed)
92929	Percutaneous transluminal revascularization of acute total/subtotal coronary occlusion; each additional vessel (List separately in addition to code for primary procedure)
92933	Percutaneous transluminal coronary thrombectomy, with or without balloon angioplasty
92934	Percutaneous transluminal coronary thrombectomy, each additional vessel (List separately in addition to code for primary procedure)
92937	Percutaneous transluminal coronary stent placement, single vessel; with coronary angioplasty when performed
92938	Percutaneous transluminal coronary stent placement, each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92943	Transcatheter therapy, with intracoronary stent placement, percutaneous
92944	Percutaneous transluminal revascularization, coronary artery, with drug-eluting stent, single vessel
92978	Transcatheter intracoronary thrombolysis
92979	Transcatheter intracoronary thrombolysis, each additional vessel

1–10 of 19

1/2

Soft tissue excision/biopsy CPT codesCPT

11626	Excision, malignant lesion including margins, trunk, arms or legs; excised diameter over 4.0 cm (soft tissue/skin excision)
11640	Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less
11641	...0.6 to 1.0 cm
11642	...1.1 to 2.0 cm
11643	...2.1 to 3.0 cm
11644	...3.1 to 4.0 cm
11646	...over 4.0 cm
11730	Trimming of nondystrophic nails, single
11765	Application of skin substitute graft (dermal)

Electrical stimulation / neurostimulator devices (review annotations)CPT

64585	Insertion or replacement of peripheral or cranial nerve neurostimulator lead(s); cranial nerve (e.g., vagus nerve stimulator) (Requires Medical Necessity Review)
64561	Percutaneous implantation of neurostimulator electrode array; peripheral nerve
63661	Implantation or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
63663	Revision or removal of spinal neurostimulator pulse generator
63650	Percutaneous implantation of neurostimulator electrode array; spinal
63655	Insertion of paddle-type neurostimulator electrode via open laminotomy
63662	Lead revision for spinal neurostimulator
63664	Removal of spinal neurostimulator system
63685	Insertion or replacement of spinal neurostimulator pulse generator (internal pulse generator), open
63688	Removal or revision of implanted neurostimulator pulse generator

1–10 of 14

1/2

Gastroenterology procedure codes (endoscopy/colonoscopy/ERCP/etc.) with per-code review flagsCPT

43229	Esophagoscopy, flexible, transoral; with directed submucosal injection, any substance
43233	Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or snare
43235	Esophagoscopy, flexible, transoral; with endoscopic mucosal resection
43236	Esophagoscopy, flexible, transoral; with dilation, therapeutic
43239	Esophagoscopy, flexible, transoral; with balloon dilation
43241	Esophagogastroduodenoscopy (EGD) with biopsy
43242	EGD with directed submucosal injection
43245	EGD with dilation
43246	EGD with injection/ablation
43248	EGD with endoscopic mucosal resection (EMR)

1–10 of 66

1/7

Autologous chondrocyte implant supply/drug HCPCSHCPCS

C2619	Autologous cultured cartilage cells, per 10 million cells (Carticel) (Requires Medical Necessity Review)
C2620	Autologous cultured cartilage implantation, per session
C2621	Autologous cultured cartilage, supply component
C1721	Tissue graft, human, per cubic centimeter (Allograft supply)
C1722	Placental-derived tissue allograft, per cm3
C1779	Allogeneic cultured cells, per unit
C1785	Implantable biologic, bone matrix (per unit)
C1786	Implantable biologic, acellular dermal matrix (per unit)
C1882	Cartilage allograft, per cm3
C1898	Wound treatment supply, bioengineered skin substitute, per sq cm

1–10 of 11

1/2

Miscellaneous specific CPT/HCPCS and Category III codes included in review listmixed

0518T	Implantation of leadless neurostimulator component (category III; Requires Medical Necessity Review)
0523T	Endoscopic full thickness resection device, insertion (category III)
0583T	Endoscopic bariatric therapy device insertion (category III)
0823T	Insertion of leadless gastric electrical stimulation system (see electrical stimulation group)
0824T	Removal of leadless gastric electrical stimulation system
0825T	Repositioning of leadless gastric electrical stimulation electrode
0826T	Replacement of leadless gastric electrical stimulation component
0861T	Transcatheter device or novel implant component (category III)
0862T	Transcatheter device or novel implant component, additional
0863T	Transcatheter device, supply

Cardiac implantable devices HCPCS/CodesHCPCS

C7540

Platelet rich plasma derived products (duplicate entry preserved for completeness)

Prior Authorization, Documentation & Billing Actions

Prior Authorization

Prior authorization is required for the site of service

Prior authorization is required for the site of service for listed elective surgical procedures. Hospital-based outpatient is the default/preferred authorization status; ASC diversion may be applied per the separate ASC Site of Care Policy.

Hospital-based outpatient is the default/preferred authorization status for elective procedures.
ASC diversion may be applied per the ASC Site of Care Policy.

Prior Authorization

Inpatient level of care prior authorization

Prior authorization for inpatient level of care for elective procedures may be approved only when the patient's clinical condition or procedural complexity clearly requires a higher level of care; approval is rare and must be supported by documentation that observation care is insufficient.

Definitions & Evidence

Definitions

Definitions (selected terms used in the criteria above):

Acute Kidney Injury: Defined as any of: increase in serum creatinine ≥1.5 times baseline within prior 7 days; increase in serum creatinine ≥0.3 mg/dL in 48 hours; reduction >50% in estimated GFR from baseline; urine volume <0.5 mL/kg/hour for 6 hours (KDIGO, 2021)
Hemodynamic Instability: Vital sign abnormality not readily corrected by appropriate treatment; includes one or more of: persistent tachycardia despite treatment, MAP <70 mm Hg, hypotension (systolic BP <90 mm Hg or decrease >40 mm Hg), persistent orthostatic hypotension despite treatment, altered level of consciousness, or shortness of breath
Apnea Hypopnea Index (AHI): Number of apneas plus hypopneas during sleep period times 60 divided by total sleep time in minutes; events per hour

Revision History

11/01/2022policy_change

MPC approved the new Elective Surgical Procedures (Level of Care) criteria (policy created and initial effective actions noted).

05/02/2024policy_change

MPC approved medical necessity review for bladder sling procedures and updated applicable codes.

07/02/2024policy_change

MPC approved addition of ASC site-of-care (ASC SOC) codes to the Level of Care policy (ASC SOC codes added).

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Elective Surgical Procedures

Policy CodePolicy N/A

Change TypeRevised (historical updates 2022–2025)

Effective Date

Next Review DateFeb 1, 2026

SourceLink

On This Page

Cognitive status that warrants inpatient stay (e.g., severe dementia with unsafe behaviors or inability to cooperate with post-op care)

Document functional status and decision-making capacity.

Severe valvular heart disease

Provide echocardiogram/consultation documentation.

Severe renal disease (e.g., GFR < 30 mL/min)

Include most recent GFR and relevant nephrology notes.

Stroke or TIA within the last 3 months

Document neurologic exam, imaging, and date of event.

Symptomatic coronary artery disease or heart failure

Document symptoms, recent testing, and cardiology recommendations.

Symptomatic chronic lung disease (e.g., severe asthma, COPD) with increased perioperative risk

Include pulmonary function testing and recent exacerbation history.

Unstable medical condition (e.g., poorly controlled diabetes with hyper/hypoglycemia, unstable seizure disorder)

Describe instability and interventions to stabilize.

Anesthetic risk that necessitates inpatient monitoring or interventions

Include anesthesiology assessment and ASA classification when available.

American Society of Anesthesiologists (ASA) class IV or V

Document ASA assignment and supporting rationale.

High risk for thromboembolism (patient-specific risk factors)

Detail risk factors and planned prophylaxis.

Age 85 years or older

Document physiologic reserve, frailty assessment, and rationale for higher level of care.

Persistent electrolyte abnormalities unresponsive to outpatient treatment (e.g., refractory hyperkalemia or hyponatremia)

Provide serial labs and treatments attempted.

Complexity of surgical procedure (anticipated unusually extensive dissection or prolonged operative time)

Surgeon’s operative plan and expected duration should be included.

Risk of postoperative airway compromise (e.g., open neck procedure, airway surgery)

Include airway risk assessment and ENT/anesthesia recommendations.

Complex surgical approach or difficult re-entry due to prior surgery

Provide prior operative reports and imaging explaining complexity.

Complex postoperative wound care needs (e.g., complex drains, open wounds, prior radiation damage, impaired local circulation)

Describe anticipated wound care and resources required.

Extensive or prolonged surgery beyond usual time frame

Surgeon’s estimate of duration and reasons for prolonged case.

Procedural-related event precluding safe outpatient care (any one of: need for preoperative diagnostics that cannot be done outpatient; conversion to open or complex procedure intraoperatively; excessive operative site bleeding/drainage; severe intraoperative complication such as bowel or vascular injury)

Detail the event and interventions; include intraoperative reports if conversion already occurred.

Ambulatory or appropriate activity level status not achieved after procedure

Document mobility assessment, PT/OT needs, and barriers to safe discharge.

Altered mental status that is severe or persistent post-procedure

Provide neurologic assessment, sedative/medication review, and expected course.

Hemodynamic instability requiring inpatient monitoring or interventions

Include vital sign trends, vasopressor use, and ICU/stepdown recommendations.

Longer postoperative monitoring or treatment needed due to preoperative use of stimulants or other drugs (e.g., cocaine, amphetamines)

Document substance use history and perioperative plan.

Severe complications of procedure anticipated or occurring (e.g., bowel injury, airway compromise, major vascular injury)

Describe complication, timing, and required level of care.

Pain, fever, or vomiting not manageable at ambulatory or observation level

Provide analgesic/antiemetic plan and prior responses to treatment.

Unstable clinical status that cannot be managed safely in outpatient/observation settings

Explain instability and why observation is insufficient.

Procedures requiring review for inpatient level of care when requested as inpatient

When an inpatient level of care is requested for elective surgical procedures, the following procedure categories require review for inpatient authorization. All listed categories (AND behavior) are subject to level-of-care review when submitted as inpatient requests; an asterisk indicates the procedure category may also require separate medical necessity review for the procedure itself.

ALL of the following

Bariatric procedures (e.g., Band lap, Roux-en-Y*, Gastric sleeve lap, Band port revision*)
Cardiac procedures (e.g., cardiac catheterization, cardiac EP procedures, pacemaker/defibrillator*)
Dermatologic procedures (e.g., Mohs surgery, biopsies, soft tissue excision)
Electrical stimulation devices (e.g., gastric electrical stimulation*, vagus nerve stimulator*, peripheral nerve stimulators)
ENT procedures (e.g., BAHA, cochlear implant*, thyroidectomy*, rhinoplasty*)
GI procedures (e.g., ERCP, colonoscopy, esophagoscopy)
General surgery (e.g., appendectomy, lap cholecystectomy, hernia repair, splenectomy)
Gynecology procedures (e.g., lap hysterectomy, hysteroscopy, vaginal hysterectomy)
Orthopedic procedures (e.g., total knee arthroplasty*, total hip arthroplasty*, arthroscopy, hip impingement surgery*)
Neurosurgery and spine procedures (e.g., discectomy, laminectomy, single-level fusion*)
Ophthalmology procedures (e.g., keratoplasty, vitrectomy)
Pain management procedures (e.g., spinal injection*, chemodenervation)
Pulmonology procedures (e.g., bronchoscopy, thoracentesis, thoracoscopy)
Restorative and cosmetic procedures (e.g., abdominoplasty/panniculectomy, breast reconstruction, blepharoplasty)
Urology procedures (e.g., circumcision >28 days, TURP, nephrectomy*)
Vascular surgery (e.g., varicose vein procedures*, revascularization)
Wound care and miscellaneous procedures (e.g., complex wound management, debridement, ASC-site-of-care codes per ASC SQC policy)

Supporting documentation required for inpatient requests

All inpatient requests for elective surgical procedures must include the following documentation. Requests will be denied or redirected to observation if supporting documentation is incomplete or does not demonstrate that observation care is insufficient.

ALL of the following

Detailed clinical rationale explaining why inpatient level of care is requested (include specific clinical concerns and how inpatient care will mitigate risk)
Tie rationale to one or more criteria in the General Criteria group; reference relevant problem lists and consult notes.
Relevant history and diagnostic results (e.g., labs, imaging, cardiopulmonary testing, MELD score, GFR) to support medical risk assessment
Include dates and trends; for AKI include baseline creatinine and urine output per Definitions: AKI.
Anticipated length of stay and a clear discharge plan (including expected disposition and post-acute services)
State expected number of midnights when known and criteria for discharge readiness.
Justification for why observation care or hospital-based outpatient management is insufficient to safely manage the patient’s post-operative needs
Describe why the risks/needs cannot be met in observation or outpatient settings (e.g., need for ongoing IV titration, complex wound care, hemodynamic monitoring).
Operative plan and procedural complexity description from the surgeon (including estimated duration, need for possible conversion to open approach, anticipated drains or blood loss)
Surgeon’s note should specify intraoperative contingencies that would necessitate inpatient care.
Relevant specialty consultations and perioperative assessments (e.g., anesthesia, cardiology, pulmonology, nephrology) documenting recommendations for inpatient monitoring when applicable
Attach consult notes or summaries supporting inpatient plan.

Documentation Required

Required supporting documentation for inpatient requests

All inpatient requests must include: detailed clinical rationale; relevant history and diagnostic results; anticipated length of stay and discharge plan; justification for why observation care is insufficient. Include last 6 months of clinical notes from the requesting provider and/or specialist.

Detailed clinical rationale
Relevant history and diagnostic results
Anticipated length of stay and discharge plan
Justification why observation is insufficient
Last 6 months of clinical notes from requesting provider and/or specialist

Denial Risk

Denial or redirection risk for insufficient documentation

Requests lacking sufficient documentation or not meeting inpatient criteria may be denied or redirected to observation level of care.

Prior Authorization

Medical necessity review required for annotated codes

Certain CPT/HCPCS codes annotated in the lists require medical necessity review before approval when submitted (examples shown below); others are listed in the policy with similar flags — obtain medical necessity review for these codes and others marked in the code lists.

64580
64581
61867
69710
69711
69714
69716
69718
69719
69726
69727
69729
27412
J7330
Other codes annotated 'Requires Medical Necessity Review' in the policy

Billing Rule

Medicare inpatient-only procedures

Codes annotated with 'X' in the policy are Medicare inpatient-only procedures; this policy does not apply to Medicare inpatient-only codes. For Medicare members follow Medicare inpatient rules and CMS guidance for those codes.

Documentation Required

Apply code-specific review annotations

When submitting claims and prior authorization requests, annotate claims and provide documentation consistent with per-code flags. Apply the per-code fields shown in the lists: Medicare IP Only (X), Requires ASC SOC Review, and Requires Medical Necessity Review — and submit supporting documentation matching those flags.

Annotate claims with per-code flags (Medicare IP Only, ASC SOC Review, Requires Medical Necessity Review).
Submit documentation consistent with the per-code review flags.

Documentation Required

Verify authorization requirements

Use the Pre-authorization Code Check to verify authorization requirements for a specific code by plan type before scheduling; this tool is referenced for plan-specific authorization verification.

ASA physical status classification: American Society of Anesthesiologists physical status classification system used to categorize patient physiological status to help predict operative risk

Medicare IP Only (X): Procedure designated Medicare inpatient-only; this policy does not apply for those codes

Requires Medical Necessity Review (X): Code requires pre-procedural medical necessity review per plan

Requires ASC SOC Review: Code requires Ambulatory Surgery Center site-of-care review when applicable

Medicare IP Only List: Procedures designated as inpatient-only for Medicare; policy does not apply to those Medicare inpatient-only procedures

Evidence summary: The policy references approximately ~60 citations supporting the clinical criteria and level‑of‑care guidance (references are listed in the full policy document).

03/03/2025policy_change

Added indication that Shoulder Arthroscopy codes and Thyroidectomy procedures require Medical Necessity review in addition to Level-of-Care review.

09/02/2025policy_changeLatest

MPC approved changes to make hospital-based outpatient care the default for elective surgeries; policy update effective 02/01/2026.