CurrentUnitedHealthcarePolicy CS182ID.B

Elective Inpatient Services (for Idaho Only)

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus). Uses InterQual criteria as a supporting source and lists medical, procedure-related, and post-procedural factors that justify inpatient admission.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Idaho Only)

Policy CodePolicy CS182ID.B

Change TypeDefinitions and references updated; no change to policy statement

Effective DateJune 1, 2026

Next Review Date

Key ActionUse InterQual criteria to support medical necessity and document the specific medical or procedure-related factors (including relevant scores such as MELD, GFR, AHI) and descriptions of instability or complications.

POLICY UPDATE CHANGES

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

8Medical condition criteria listed

6Procedure/anesthetic risk criteria listed

11Post-procedural/complication criteria listed

Covered with criteriaCoverage stance

This policy (CS182ID.B) defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus. Coverage stance: covered_with_criteria. Subject: Elective inpatient services (Idaho). Status: CURRENT. Effective / Last review date: June 1, 2026. The policy uses InterQual criteria as a supporting source to assess medical necessity and level of care. Note: the policy does not apply to obstetric members during pregnancy, childbirth, or the post-partum period.

Threshold summary

MELD Score> 8

GFR<= 30 mL/min

Apnea Hypopnea Index (AHI) - moderate15-30 events/hour

Apnea Hypopnea Index (AHI) - severe> 30 events/hour

KDIGO AKI criteria (serum creatinine/urine output)Increase in serum creatinine ≥ 0.3 mg/dL in 48 hours OR ≥1.5x baseline within 7 days OR urine volume <0.5 mL/kg/hour for 6 hours OR >50% reduction in eGFR

Hemodynamic instability—systolic BPSystolic BP < 90 mm Hg or decrease > 40 mm Hg

Hemodynamic instability—MAPMean arterial pressure (MAP) < 65 mm Hg

Hemodynamic instability—capillary refillNew abnormal capillary refill > 3 seconds

Statistics

Example medical condition criteria listed8

Procedure/anesthetic risk criteria listed6

Post-procedural/complication criteria listed11

Provider Actions and Documentation Requirements

Documentation Required

Support inpatient admission with InterQual and clinical documentation

Use InterQual criteria as supporting documentation for medical necessity and record the specific medical or procedure-related factors that meet policy criteria. Include relevant scores and descriptions of instability or complications in the clinical record.

MELD score (report value; threshold: > 8)
GFR value (report eGFR; threshold: ≤ 30 mL/min)
Apnea-Hypopnea Index (AHI) with severity (moderate 15–30, severe > 30)
Descriptions of hemodynamic instability or other complications (e.g., hypotension, oliguria, altered consciousness, excessive bleeding)

Documentation Required

Document acute kidney injury per KDIGO criteria when present

When Acute Kidney Injury (AKI) is cited as a reason for inpatient admission, document the elements necessary to meet KDIGO definitions and to justify the inpatient level of care.

Serum creatinine changes (e.g., ≥ 0.3 mg/dL increase in 48 hours or ≥1.5× baseline within 7 days)
Urine output (e.g., < 0.5 mL/kg/hour for 6 hours)
Baseline kidney function values (baseline serum creatinine and baseline eGFR)

Definitions and Evidence / Rationale

Applicability: this medical policy applies only in the state of Idaho, and includes Idaho Medicaid Plus plans. UnitedHealthcare uses InterQual criteria as a source to support medical necessity and level of care decisions. The policy explicitly excludes obstetric members during pregnancy, childbirth, or the post-partum period.

Quick Definitions

Definitions

Acute Kidney Injury: Defined per KDIGO: increase in serum creatinine ≥ 0.3 mg/dL in 48 hours; or ≥1.5x baseline within 7 days; or reduction >50% in eGFR; or urine volume <0.5 mL/kg/hour for 6 hours.KDIGO AKI criteria
Apnea Hypopnea Index (AHI): Number of apneas plus hypopneas per hour of sleep; moderate AHI 15-30, severe AHI >30.AHI 15-30 (moderate); >30 (severe)
Hemodynamic Instability: Vital sign abnormality not readily corrected including systolic BP <90 mm Hg, MAP <65 mm Hg, oliguria, new abnormal capillary refill >3s, altered consciousness, shortness of breath, persistent tachycardia.Systolic BP <90 mm Hg; MAP <65 mm Hg; capillary refill >3s

Evidence sources

AHA/ACC/ACS guideline referenced2024 AHA/ACC/ACS perioperative cardiovascular management guideline for noncardiac surgery

KDIGO AKI definition referencedKDIGO 2012 AKI criteria (serum creatinine rises, eGFR reduction, urine output thresholds)

Clinical Thresholds and Parameters

Numeric thresholds

MELD Score> 8

GFR<= 30 mL/min

AHI - moderate15-30 events/hour

AHI - severe> 30 events/hour

AKI - serum creatinine riseIncrease ≥ 0.3 mg/dL in 48 hours OR ≥1.5x baseline within 7 days

AKI - urine outputUrine volume < 0.5 mL/kg/hour for 6 hours

Hemodynamic - systolic BPSystolic BP < 90 mm Hg or decrease > 40 mm Hg

Hemodynamic - MAPMAP < 65 mm Hg

Hemodynamic - capillary refill> 3 seconds

Revision History

06/01/2026revisedLatest

Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and updated Clinical Evidence and References sections. 06/01/2026 revision notes indicate definitions and references updates; policy statement unchanged.