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    OpenPayerPolicy UpdatesClinical/Medical PolicyMass General Brigham Surgical Coverage | OpenPayer
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    CurrentMass General Brigham Health PlanPolicy 116

    Medical Necessity Guidelines Inpatient Surgical Care

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    Governs medical necessity review and prior authorization for elective inpatient surgical care when applicable InterQual subsets do not exist, including Medicare Advantage, Mass General Brigham ACO, One Care/SCO, Commercial, and Qualified Health Plan members.

    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyMedical Necessity Guidelines Inpatient Surgical Care
    Policy CodePolicy 116
    Change TypeClarificationno material change
    Effective DateAug 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateNot specified
    Key ActionObtain prior authorization for elective inpatient surgical care before service for applicable members.
    SourceLink
    POLICY UPDATE CHANGES

    The November 1, 2026 ad hoc review corrected wording describing the CMS Two Midnight Benchmark.

    4Plan/product categories requiring prior authorization
    2 midnightsMedicare Advantage hospital-care threshold
    ASA III or IVRequired physical-status classification
    6High-risk thromboembolism condition categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    InterQualConcurrent or post-service review criteria

    Elective Inpatient Surgical Coverage Criteria

    Medicare Advantage elective inpatient criteria

    For Medicare Advantage, the elective procedure must be authorized or not require prior authorization, and at least one pathway below must be met.

    Medicare Advantage inpatient-care pathways

    • CMS Inpatient Only pathway: The requested surgical procedure is on the CMS Inpatient Only List.
    • Commercial-criteria pathway: Mass General Brigham Health Plan commercial criteria for pre-service authorization of inpatient hospital care are met.
    • Two Midnight pathway: Clinical documentation indicates that the member will require medically necessary hospital care spanning at least two midnights.at least two midnights

      Requires secondary review.

    Commercial, Qualified Health Plan, and ACO elective inpatient criteria

    For Mass General Brigham ACO members, apply the Commercial and Qualified Health Plan criteria because MassHealth does not provide medical necessity guidelines for inpatient surgical care. For Commercial and Qualified Health Plan members, the elective procedure must be authorized or not require prior authorization, and at least one pathway below must be met.

    Commercial inpatient-care pathways

    • InterQual inpatient procedure pathway: The requested surgical procedure is listed on the InterQual Procedures Setting by CPT Code Report as an inpatient-setting procedure.

    • Postoperative unfractionated-heparin bridge pathway

      • Anticoagulation prerequisites: The member takes warfarin, and low molecular weight heparin is contraindicated in the postoperative setting.

      • High-risk thromboembolism condition

    One Care and SCO review framework

    For One Care and Senior Care Options members, CMS guidance is used first. When CMS guidance is unavailable or the member does not meet all applicable medical necessity criteria, MassHealth guidelines are used.

    One Care and SCO review framework: Apply CMS medical necessity guidance first, then apply MassHealth medical necessity guidelines when CMS guidance is unavailable or the member does not meet all applicable medical necessity criteria; use the Medicare Advantage criteria above as directed.

    Clinical Thresholds and Classification Values

    Coding
    RequirementMedically necessary hospital care spanning at least two midnights
    Applies toMedicare Advantage elective inpatient hospital review
    Review noteThe two-midnight pathway requires secondary review
    Coding
    RequirementAt least two postoperative nights in the hospital
    PurposeMedically necessary postoperative care
    Related classificationThe patient must also have an ASA Physical Status Classification of III or IV

    Authorization and Documentation Requirements

    Prior Authorization

    Medicare Advantage Prior Authorization Required

    Prior authorization is required for Medicare Advantage inpatient surgical care. Pre-service authorization may be granted when the elective surgical procedure is authorized, or does not require prior authorization, and at least one applicable inpatient criterion is met.

    • The procedure is listed on the CMS Inpatient Only List; or
    • Mass General Brigham Health Plan commercial criteria for pre-service authorization of inpatient hospital care are met; or
    • Clinical documentation indicates the member will require medically necessary hospital care spanning at least two midnights; this pathway requires secondary review.
    Prior Authorization

    ACO Prior Authorization Required

    Prior authorization is required for Mass General Brigham ACO inpatient surgical care. MassHealth guidance is used when available; because MassHealth does not provide medical necessity guidelines for inpatient surgical care, the Plan applies its Commercial and Qualified Health Plan criteria.

    Policy Scope and Review Context

    This policy guides medical necessity review for prospective elective inpatient surgical care when an applicable InterQual subset is not available. It evaluates whether the procedure should be performed in an inpatient hospital setting rather than in a lower-acuity setting, such as an outpatient or other noninpatient setting. For Commercial and Qualified Health Plan members, inpatient authorization may be supported by the InterQual procedure-setting designation, a qualifying need for postoperative unfractionated-heparin bridging, or an expected stay of at least two postoperative nights together with an ASA III or IV condition.

    The policy applies across Mass General Brigham Health Plan products, including Medicare Advantage, Mass General Brigham ACO, One Care and Senior Care Options, Commercial, and Qualified Health Plans. Review requirements vary by product: Medicare Advantage incorporates CMS inpatient-care standards, including the Inpatient Only List and the Two Midnight Benchmark, while ACO, One Care, SCO, Commercial, and Qualified Health Plan reviews follow the product-specific guidance described in the policy. Prior authorization is required for elective inpatient surgical care when applicable.

    ASA Physical Status Classifications

    Definitions
    DefinitionA patient with severe systemic disease
    Representative examplesCOPD, morbid obesity (BMI ≥40), active hepatitis, compensated cirrhosis, or alcohol dependence or abuse
    Additional examplesESRD undergoing regularly scheduled dialysis, moderate reduction of ejection fraction or CHF NYHA class 2 or 3, or a history more than 3 months previously of MI, CVA, TIA, PE, or CAD/stents
    Definitions
    DefinitionA patient with severe systemic disease that is a constant threat to life
    Representative examplesRecent (less than 3 months) MI, CVA, TIA, or CAD/stents; ongoing cardiac ischemia; or severe valve dysfunction
    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyMedical Necessity Guidelines Inpatient Surgical Care
    Policy CodePolicy 116
    Change TypeClarificationno material change
    Effective DateAug 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateNot specified
    Key ActionObtain prior authorization for elective inpatient surgical care before service for applicable members.
    SourceLink
    On This Page
    Elective Inpatient Surgical Coverage CriteriaClinical Thresholds and Classification ValuesAuthorization and Documentation RequirementsPolicy Scope and Review ContextASA Physical Status Classifications
    Mechanical heart valve with a major stroke risk factor, a caged-ball or tilting-disc valve in the mitral or aortic position, or stroke/TIA within the last 3 months.

    Major stroke risk factors include atrial fibrillation, prior stroke/TIA, prior valve thrombosis, rheumatic heart disease, hypertension, diabetes, congestive heart failure, or age 75 years or older.

  1. Atrial fibrillation with a CHA2DS2-VASc score of 7 or greater, a CHADS2 score of 5 or greater, stroke/TIA within the last 3 months, or rheumatic valvular heart disease.CHA2DS2-VASc >= 7 or CHADS2 >= 5; recent stroke/TIA within the last 3 months
  2. Recent VTE: Venous thromboembolism within the last 3 months.within the last 3 months
  3. Severe thrombophilia, including deficiency of protein C, protein S, or antithrombin; homozygous factor V Leiden or prothrombin gene G20210A mutation; double heterozygosity for these mutations; or multiple thrombophilias.
  4. Antiphospholipid antibodies: Presence of antiphospholipid antibodies.
  5. Active cancer with high VTE risk: Active cancer associated with high VTE risk, such as pancreatic cancer, myeloproliferative disorders, primary brain cancer, gastric cancer, or esophageal cancer.
  6. Two-night and ASA pathway: Clinical documentation indicates that the patient is expected to require at least two postoperative nights in the hospital for medically necessary care, and the member has an ASA Physical Status Classification of III or IV.at least two postoperative nights; ASA III or IV

    ASA examples are provided in the Definitions section.

    7. Coding
    ThresholdCHA2DS2-VASc score of 7 or greater
    Clinical contextAtrial fibrillation associated with high risk of thromboembolism
    PathwayQualifying condition for the postoperative unfractionated-heparin bridge pathway
    Coding
    ThresholdCHADS2 score of 5 or greater
    Clinical contextAtrial fibrillation associated with high risk of thromboembolism
    PathwayQualifying condition for the postoperative unfractionated-heparin bridge pathway
    Coding
    Time frameWithin the last 3 months
    Clinical significanceAssociated with high risk of thromboembolism
    Qualifying settingsMay qualify in the mechanical heart valve or atrial fibrillation pathways
    Prior Authorization

    One Care and SCO Review Framework

    Prior authorization is required for One Care and Senior Care Options (SCO) inpatient surgical care. Apply CMS guidance first, including applicable NCDs, LCDs, LCAs, and Medicare-manual documentation; when CMS guidance is unavailable or the member does not meet all applicable criteria, use MassHealth guidelines and the Medicare Advantage criteria above.

    Prior Authorization

    Commercial and QHP Prior Authorization Required

    Prior authorization is required for elective inpatient surgical care for Commercial and Qualified Health Plan members. The elective surgical procedure must be authorized, or not require prior authorization, and at least one applicable inpatient criterion must be met.

    Documentation Required

    Document Expected Two-Midnight Care

    For the Medicare Advantage two-midnight pathway, submit clinical documentation supporting that the member will require medically necessary hospital care spanning at least two midnights. This pathway is subject to secondary review.

    • Document the expected medically necessary inpatient services and clinical factors supporting care across at least two midnights.
    • The elective surgical procedure must be authorized or must not require prior authorization.
    Documentation Required

    Support Anticoagulation, Length-of-Stay, and ASA Criteria

    For Commercial and Qualified Health Plan authorization, submit documentation supporting the applicable inpatient criterion. If relying on postoperative anticoagulation, document warfarin use, contraindication to postoperative low molecular weight heparin, and the qualifying high-thromboembolism-risk condition.

    • The procedure is listed as an inpatient-setting procedure on the InterQual Procedures Setting by CPT Code Report.
    • For an unfractionated heparin bridge: the member takes warfarin; low molecular weight heparin is contraindicated postoperatively; and the member has a qualifying high-risk condition, including specified mechanical heart valve risk, qualifying atrial fibrillation, recent stroke or TIA, rheumatic valvular heart disease, VTE within the last 3 months, severe thrombophilia, antiphospholipid antibodies, or active cancer associated with high VTE risk.
    • Alternatively, document that the patient is expected to require at least two postoperative hospital nights for medically necessary care and has an ASA Physical Status Classification System class III or IV condition.
    Denial Risk

    Medicare Advantage Inpatient Criteria Not Met

    Medicare Advantage elective inpatient authorization may be denied when the elective surgical procedure is not authorized, when authorization is required and has not been obtained, or when none of the applicable inpatient criteria is met.

    • The procedure is not on the CMS Inpatient Only List.
    • Mass General Brigham Health Plan commercial criteria for pre-service inpatient authorization are not met.
    • Clinical documentation does not support medically necessary hospital care spanning at least two midnights, after required secondary review.
    Denial Risk

    Commercial Inpatient Criteria Not Met

    Commercial and Qualified Health Plan elective inpatient authorization may be denied when the procedure is not authorized, when authorization is required and has not been obtained, or when the submitted documentation does not meet an applicable inpatient criterion.

    • The procedure is not listed as an inpatient-setting procedure on the InterQual Procedures Setting by CPT Code Report.
    • The postoperative unfractionated-heparin-bridge criteria are not all met or are not supported by documentation.
    • The patient is not expected to require at least two postoperative hospital nights for medically necessary care, or the member does not have an ASA class III or IV condition.
    Prior Authorization

    InterQual Concurrent or Post-Service Review

    Following an urgent or emergent admission to an acute care hospital, submit the case for concurrent or post-service inpatient authorization review using the applicable InterQual criteria.

    • Use the InterQual General Surgical, General Trauma, or other service-specific subset as applicable.
    Additional examplesShock, sepsis, DIC, ARDS, severe reduction of ejection fraction or CHF NYHA class 4, ESRD without regularly scheduled dialysis, or uncompensated cirrhosis