CurrentUnitedHealthcare Community Plan (Ohio)Policy CS182OH.D

Elective Inpatient Services (for Ohio Only) – Community Plan Medical Policy

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries/procedures for UnitedHealthcare Community Plan members in Ohio, referencing InterQual and Ohio Administrative Code for evaluation when applicable. Excludes obstetric admissions during pregnancy, childbirth, or postpartum.

Policy Summary

PayerUnitedHealthcare Community Plan (Ohio)

PolicyElective Inpatient Services (for Ohio Only) – Community Plan Medical Policy

Policy CodePolicy CS182OH.D

Change TypeRevised definitions and updated references (03/01/2026)

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must document one or more listed medical-condition, procedure-related, logistical, or procedural-event criteria when requesting elective inpatient admission to support medical necessity under this policy.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and updated Clinical Evidence and References sections.

Ohio-onlyGeographic scope

InterQualPrimary criteria source

Obstetric admissions excludedExclusion

Coverage Summary

UnitedHealthcare Community Plan (Ohio) uses InterQual as the primary source to support medical necessity and level-of-care decisions for elective inpatient services. This policy applies only to the state of Ohio and is identified as Policy Number CS182OH.D with an effective date of March 1, 2026. Federal, state (including the Ohio Administrative Code), or contractual definitions and requirements supersede the policy when there is a conflict.

The policy defines clinical, procedure-related, logistical, and complication-based criteria that justify planned elective inpatient admissions. It excludes obstetric admissions during pregnancy, childbirth, or the postpartum period. Coverage stance: covered_with_criteria.

Thresholds and Policy Stats

MELD Score> 8

GFR<= 30 mL/min

Stroke/TIA timeframewithin last 3 months

Age>= 85 years

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

Acute Kidney Injury (AKI) criteriaIncrease in serum creatinine >= 0.3 mg/dL in 48 hours; or >=1.5x baseline within prior 7 days; or >50% reduction in eGFR; or urine volume <0.5 mL/kg/hour for 6 hours

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

Geographic scopeOhio-only

ExclusionObstetric admissions excluded

Primary criteria sourceInterQual referenced

Medically Necessary Criteria for Planned 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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Definitions and Evidence

UnitedHealthcare Community Plan (Ohio) relies on InterQual criteria to support medical necessity and level-of-care determinations, used in conjunction with the independent professional judgment of a qualified health care provider.

This Medical Policy applies only in Ohio; requests for services listed as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. The policy also notes that it does not apply to obstetric members during pregnancy, childbirth, or the post-partum period.

Term	Definition
Acute Kidney Injury
Defined as increase in serum creatinine >= 0.3 mg/dL in 48 hours; or increase in serum creatinine >= 1.5 times baseline within the prior 7 days; reduction of more than 50% in estimated glomerular filtration rate from baseline; or urine volume < 0.5 mL/kg/hour for 6 hours (KDIGO, 2012).
Apnea Hypopnea Index (AHI)
Number of apneas plus hypopneas during the entire sleeping period, times 60, divided by total sleep time in minutes; unit: events per hour; AHI thresholds: mild 5-<15, moderate 15-30, severe >30 (AASM, 2008).
Hemodynamic Instability
Vital sign abnormality not readily corrected by appropriate treatment as indicated by one or more of: systolic blood pressure < 90 mm Hg or decrease in systolic BP > 40 mm Hg; urine output goal oliguria 0.5 mL/kg/hour; MAP < 65 mm Hg; new abnormal capillary refill > 3 seconds; altered level of consciousness; shortness of breath; persistent tachycardia.
ASA Physical Status Classification
Six-class system (ASA I-VI) categorizing patient's pre-anesthesia physiological status; ASA III or greater considered higher anesthetic risk.

Evidence Sources

Guideline sources referencedInterQual; AASM; AHA/ACC perioperative guideline (2024); ASA statements; GINA 2023; KDIGO 2012

Provider Actions / Prior Authorization

Documentation Required

Document medical necessity criteria

Providers must document one or more listed medical-condition, procedure-related, logistical, or procedural-event criteria when requesting elective inpatient admission to support medical necessity under this policy. The policy lists clinical, procedure-related, logistical, and complication-based factors (for example: advanced liver disease, severe renal disease, ASA class III or greater, age ≥85, complex surgical approach, need for preoperative diagnostic studies not performable as an outpatient, distant residence with potential for urgent complications, acute kidney injury, hemodynamic instability, conversion to open procedure, excessive bleeding, persistent altered mental status, and other unstable clinical conditions) that justify planned elective inpatient admissions. Providers should include documentation of the specific criterion(ia) that apply to the individual when requesting inpatient admission.

Providers must document one or more listed medical-condition, procedure-related, logistical, or procedural-event criteria when requesting elective inpatient admission.

Prior Authorization

Prior authorization evaluated per Ohio rules

Requests for services stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. UnitedHealthcare uses InterQual as a source of medical evidence to support medical necessity and level of care decisions and InterQual criteria may be used as supporting evidence when applicable.

Ohio Administrative Code 5160-1-01 applies to evaluation of unproven services or services with coverage/quantity limits; InterQual may be used as supporting evidence.