CurrentUnitedHealthcarePolicy CS182ID.A

Elective Inpatient Services (for Idaho Only)

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for UnitedHealthcare Community Plan members in Idaho (including Idaho Medicaid Plus). Uses InterQual criteria as supporting evidence and lists clinical, procedural, and patient factors that justify inpatient admission.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Idaho Only)

Policy CodePolicy CS182ID.A

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting inpatient admission, providers should document that one or more listed clinical, procedural, or patient factors are present and reference InterQual criteria as supporting evidence.

POLICY UPDATE CHANGES

New Medical Policy created effective 06/01/2025

Idaho-onlyState scope

Covered w/ criteriaCoverage stance

ObstetricExclusion population

Coverage Summary

This policy (Policy Number: CS182ID.A) defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus. Effective date is June 1, 2025 and the policy is new as of that effective date.

Coverage stance: Covered with criteria — elective inpatient admission is considered medically necessary when one or more listed clinical, procedural, or patient factors are present (for example: MELD Score > 8; GFR < 30 mL/min; ASA Physical Status Class III or greater; AHI moderate 15–30 or severe >30; and specified acute kidney injury thresholds). Providers should document applicable factors and may expect payor review against InterQual criteria, which UnitedHealthcare uses as supporting evidence for level-of-care decisions.

InterQual criteria are used as the supporting evidence source for the clinical rules and thresholds in this policy. National guidance referenced explicitly in the policy includes the American Academy of Sleep Medicine (AASM), American College of Cardiology/American Heart Association (ACC/AHA), American Heart Association (AHA), American Society of Anesthesiologists (ASA), and the Global Initiative for Asthma (GINA).

Provider Actions / Prior Authorization

Documentation Required

Document medical necessity per InterQual-supported criteria

When requesting inpatient admission, providers should document that one or more listed clinical, procedural, or patient factors are present and reference InterQual criteria as supporting evidence.

Prior Authorization

Prior authorization reference to InterQual criteria

UnitedHealthcare uses InterQual criteria to support medical necessity and level-of-care decisions; providers should expect payor review against InterQual when seeking authorization for elective inpatient admissions.

Providers should expect payor review against InterQual when seeking authorization.

Background & Evidence

UnitedHealthcare Community Plan Idaho uses InterQual criteria to determine medical necessity and level of care for elective inpatient surgical admissions. The InterQual-supported coverage rationale lists specific clinical conditions, physiologic thresholds, and procedure-related risk factors that justify inpatient admission and instructs providers to document that one or more listed factors are present when requesting inpatient admission.

Referenced national society guidance cited in the policy includes AASM (sleep apnea severity thresholds), ACC/AHA (perioperative cardiovascular evaluation guidance), AHA (stages of heart failure), ASA (physical status classification and perioperative OSA management), and GINA (asthma perioperative considerations).

Scope note: This policy applies Idaho-only (including Idaho Medicaid Plus) and does not apply to obstetric members during pregnancy, childbirth, or the post‑partum period.

Sources referenced

InterQualInterQual criteria used to support medical necessity and level of care decisions

AASM 2008Obstructive Sleep Apnea severity definitions referenced

ACC/AHA 2014Perioperative cardiovascular evaluation and management guidance referenced

AHA stages of heart failureFour stages (A-D) referenced

ASA guidance 2014 and 2020ASA perioperative guidance and ASA Physical Status classification referenced

GINA 2023Asthma perioperative risk and management considerations referenced

Acute Kidney InjuryIncrease in serum creatinine >1.5x baseline within 7 days OR increase >=0.3 mg/dL in 48 hours OR >50% reduction in eGFR from baseline

Apnea Hypopnea Index (AHI)Number of apneas plus hypopneas per hour of sleep; moderate 15-30 events/hour; severe >30 events/hour

ASA Physical Status ClassificationSubjective pre-anesthesia health assessment; Class III or greater indicates severe systemic disease and higher perioperative risk

Hemodynamic InstabilityVital sign abnormalities not readily corrected, e.g., oliguria <0.5 mL/kg/hr, SBP <90 mmHg or drop >40 mmHg, MAP <65 mmHg, altered consciousness, capillary refill >3 sec, shortness of breath, persistent tachycardia

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Idaho Only)

Policy CodePolicy CS182ID.A

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

On This Page

OpenPayer

Elective Inpatient Services (for Idaho Only)

Coverage Summary

Medical-Necessity Criteria

Provider Actions / Prior Authorization

Coding

Background & Evidence

Revision History