CurrentUnitedHealthcarePolicy CS182TN.G

Elective Inpatient Services (for Tennessee Only)

Defines medical necessity criteria for planned elective inpatient admissions for surgeries/procedures for Tennessee Medicaid and CoverKids, including patient risk factors, procedure-related risks, need for preoperative studies, and procedural events that may require inpatient stays. Excludes obstetric care.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Tennessee Only)

Policy CodePolicy CS182TN.G

Change TypeDefinition and references updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionProvider must document which specific medical condition(s), procedure-related risk(s), or procedural event(s) meet the listed criteria to justify planned elective inpatient admission under Tennessee Medicaid/CoverKids.

POLICY UPDATE CHANGES

Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and updated supporting information, clinical evidence, and references.

1State-specific policy (Tennessee)

MultipleClinical criteria categories

Coverage Summary

This policy defines medical necessity criteria for planned elective inpatient admissions for certain surgeries and procedures for Tennessee Medicaid and CoverKids. It is covered with criteria when the listed medical conditions, procedure-related risk factors, or procedural events are met (for example: MELD score > 8, GFR <= 30 mL/min, ASA Class III or greater, AHI thresholds, recent stroke/TIA, hemodynamic instability, or need for inpatient monitoring). The policy explicitly excludes obstetric members during pregnancy, childbirth, and the post-partum period.

Key thresholds and policy dates

MELD Score> 8

GFR<= 30 mL/min

Stroke/TIA recencywithin last 3 months

Age>= 85 years

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

Acute Kidney Injury (AKI) diagnostic thresholdsIncrease in serum creatinine >=0.3 mg/dL in 48 hrs OR >=1.5x baseline within 7 days OR >50% reduction in eGFR OR urine <0.5 mL/kg/hr for 6 hrs

Hemodynamic Instability criteriaAny of: SBP <90 mm Hg or decrease >40 mm Hg; MAP <65 mm Hg; oliguria; new capillary refill >3 sec; altered consciousness; shortness of breath; persistent tachycardia

Effective dateFebruary 1, 2026

Last reviewFebruary 1, 2026

Medical Necessity — Elective Inpatient Admission

Medically necessary 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:

ANY of the following

Medical conditions increasing the risk of major post-operative complications
- Advanced liver disease (MELD Score > 8)> 8
  MELD score threshold explicitly > 8
- Cognitive status that warrants inpatient stay
- Severe renal disease (GFR <= 30 mL/min)GFR <= 30 mL/min
- Severe valvular heart disease
- Stroke or TIA within last 3 monthswithin last 3 months
- Symptomatic chronic lung disease (e.g., asthma, COPD)
- Symptomatic coronary artery disease or heart failure
- Unstable medical condition (e.g., poorly controlled diabetes)
Procedure-related factors that may increase the risk of complications
- Anesthetic risk: American Society of Anesthesiologists class III or greaterASA III or greater
  ASA III or greater
- Age 85 years or older>= 85 years
- High risk for thromboembolism
- Moderate (AHI 15-30) to severe (AHI > 30) sleep apneaAHI >= 15 (moderate) or AHI > 30 (severe)
- Persistent electrolyte abnormalities unresponsive to treatment (e.g., hyperkalemia, hyponatremia)
Other indications for inpatient admission
- The need for preoperative diagnostic studies that cannot be performed as an outpatient
- ALL of the following
  - Individual's residence is distant to medical facility and there is a potential for urgent complications and no other nearby temporary residence is available and not appropriate for ambulatory or observation level of care
  - Pre- or post-operative inpatient monitoring or treatment related to need to discontinue drugs or other therapies
- ALL of the following
  - Acute Kidney InjurySee Definitions for AKI diagnostic thresholds
    See Definitions for AKI diagnostic thresholds

ref

Provider Actions & Utilization Review

Documentation Required

Document medical necessity criteria

Provider must document which specific medical condition(s), procedure-related risk(s), or procedural event(s) meet the listed criteria to justify planned elective inpatient admission under Tennessee Medicaid/CoverKids.

Prior Authorization

Use of InterQual as supporting evidence

UnitedHealthcare may use InterQual criteria to support medical necessity and level-of-care decisions; providers should anticipate utilization review referencing InterQual when applicable.

Definitions & Clinical Thresholds

Applies to Tennessee Medicaid and CoverKids. UnitedHealthcare may use InterQual criteria as a supporting tool for medical necessity and level-of-care decisions. This policy does not apply to obstetric members during pregnancy, childbirth, or the post-partum period.

Term	Definition
Acute Kidney Injury
Defined by KDIGO: 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; or reduction of more than 50% in estimated glomerular filtration rate from baseline; or urine volume < 0.5 mL/kg/hour for 6 hours.
AHI
The number of apneas plus hypopneas per hour of sleep; unit: events/hour.
OSA severity
Mild: AHI ≥5 and <15; Moderate: AHI ≥15 and ≤30; Severe: AHI >30/hour.
Hemodynamic Instability
Vital sign abnormality not readily corrected by appropriate treatment as indicated by one or more of: systolic BP <90 mm Hg or decrease in systolic BP >40 mm Hg; oliguria (urine output goal 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 classification
Subjective assessment of overall health using the American Society of Anesthesiologists Physical Status Classification System (ASA I–VI); ASA III or greater indicates severe systemic disease or higher operative risk.

Quick reference thresholds

MELD Score> 8

GFR<= 30 mL/min

Stroke/TIAwithin last 3 months

Age>= 85 years

AHI categoriesModerate 15-30; Severe >30 events/hour

AKI thresholdsSCr +>=0.3 mg/dL/48 hrs OR >=1.5x baseline/7 days OR >50% eGFR reduction OR urine <0.5 mL/kg/hr x6 hrs

Hemodynamic InstabilitySBP <90 or drop >40; MAP <65; oliguria; cap refill >3s; altered consciousness; SOB; persistent tachycardia