Currentsierra health and lifePolicy MP.11.26

Outpatient Surgical Procedures - Site of Service

Policy defines medical-necessity criteria for performing planned surgical procedures in a hospital outpatient department vs an ambulatory surgical center (ASC) for UnitedHealthcare Commercial and Individual Exchange plans (with state exceptions) and describes when outpatient hospital setting is considered medically necessary.

Policy Summary

Payersierra health and life

PolicyOutpatient Surgical Procedures - Site of Service

Policy CodePolicy MP.11.26

Change TypeTemplate update; shared policy creation; annual CPT edits

Effective DateJan 1, 2026

Next Review Date

Key ActionConduct site-of-service medical necessity reviews for surgical procedures on the Applicable Codes List when performed in an outpatient hospital setting and follow plan-specific code lists and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Template Update and creation of shared policy version to support application to Oxford plan membership; added language excluding Massachusetts for Individual Exchange.

1Applicable CPT/HCPCS code list referenced (external)

22Listed clinical criteria for hospital outpatient medical necessity

Coverage Summary

This policy defines medical-necessity criteria for performing planned surgical procedures in a hospital outpatient department versus an ambulatory surgical center (ASC). It applies to UnitedHealthcare Commercial benefit plans (except UnitedHealthcare West) and to most Individual Exchange plans (excluding Massachusetts, Nevada, Texas, and Wisconsin), and is intended to guide site-of-service medical necessity reviews; however, coverage is ultimately governed by the member-specific benefit plan document and any applicable laws.

Medical-Necessity Criteria

Medically Necessary in Hospital Outpatient Department

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria:

Medically Necessary in Hospital Outpatient Department - Top Level

Advanced liver disease (MELD Score > 8)> 8
Overnight recovery need: Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Anticipated transfusion: Anticipated need for transfusion
Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect
Cardiac arrhythmia (symptomatic arrhythmia despite medication)
COPD: Chronic obstructive pulmonary disease (COPD) (FEV1 < 50%)< 50%
CAD/PVD: Coronary artery disease (CAD)/peripheral vascular disease (PVD) [ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stent]DES < 1 year
Developmental/cognitive status: Developmental stage or cognitive status warranting use of a hospital outpatient department
End stage renal disease [(hyperkalemia above reference range) receiving peritoneal or hemodialysis]
Recent CVA/TIA: History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) [recent event (< 3 months)]< 3 months
Recent MI: History of myocardial infarction (MI) [recent event (< 3 months)]< 3 months
Recent coronary intervention: 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 < 1 year; BMS/plain angioplasty < 90 days
Myocardial ischemia: Ongoing evidence of myocardial ischemia
Poorly controlled asthma: Poorly Controlled asthma (FEV1 < 80% despite medical management)< 80% despite medical management
Pregnancy
Prolonged surgery (> 3 hours)> 3 hours
Resistant hypertension (Poorly Controlled)
Severe valvular heart disease
Sleep apnea [moderate to severe Obstructive Sleep Apnea (OSA)]moderate to severe (AHI or RDI ≥ 15)
Uncompensated CHF: Uncompensated chronic heart failure (CHF) (NYHA class III or IV)
Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia
Pediatric: Under 18 years of age< 18 years

Placeholder

Medically Necessary if ASC inaccessible

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to any one of the following:

Medically Necessary if ASC inaccessible - Top Level

ASC guideline exclusion: An ASC's specific guideline regarding the individual's health conditions or weight that would preclude management of an individual within an ASC setting
No geographically accessible ASC with necessary equipment: There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, and nonstandard scopes required to perform specialized procedures (i.e., duodenoscope, ureteroscope)). Note: specifically excludes surgeon preferred or proprietary instruments, instrument sets, or hardware sets.
Examples: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes (duodenoscope, ureteroscope)
No ASC with physician privileges:

Provider Actions

Prior Authorization

Site of Service medical necessity review required

Site-of-service reviews will be conducted for surgical procedures on the Applicable Codes List when performed in an outpatient hospital department; refer to the plan-specific CPT/HCPCS code lists and the Individual Exchange advanced notification/prior authorization requirements for plan-level requirements.

Commercial Plans: Outpatient Surgical Procedures - Site of Service: CPT/HCPCS Code List
Individual Exchange Plans: UHCProvider.com > Exchange Plans Advanced Notification/Prior Authorization Requirements

Documentation Required

Medical records documentation may be required

Medical records documentation may be requested to assess whether the member meets the clinical criteria for coverage, and benefit coverage is determined by the member-specific benefit plan document.

Documentation should support the listed clinical criteria and thresholds (for example MELD > 8, FEV1 thresholds, OSA severity, recent MI/CVA timeframes, surgical duration > 3 hours).

Definitions & Background

This policy governs when the use of a hospital outpatient department for an outpatient surgical procedure is considered medically necessary instead of care in an ambulatory surgical center (ASC). It applies to UnitedHealthcare Commercial plans (with plan exceptions noted) and to Individual Exchange plans in most states (state exceptions noted), and member-specific benefit documents determine final coverage. Site-of-service medical necessity reviews will be conducted for procedures listed on the applicable codes list when performed in an outpatient hospital setting.

ASA Physical Status Classification System Risk Scoring Tool: The American Society of Anesthesiologists subjective assessment of a patient’s overall health based on five classes.

Obstructive Sleep Apnea (OSA): Defined by the AASM as mild for AHI/RDI ≥5 and <15; moderate for AHI/RDI ≥15 and ≤30; and severe for AHI/RDI >30/hr.

Poorly Controlled (hypertension): Requiring three or more drugs to control blood pressure.

OpenPayer

Outpatient Surgical Procedures - Site of Service

Coverage Summary

Medical-Necessity Criteria

Applicable Codes

Provider Actions

Definitions & Background

Revision History