CurrentUnitedHealthcarePolicy CS182TN.G

Elective Inpatient Services (Tennessee Only)

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for Tennessee Medicaid and CoverKids members, including medical, procedural, preoperative, and perioperative factors that justify inpatient rather than outpatient/observation care. Excludes obstetric care during pregnancy, childbirth, or postpartum.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (Tennessee Only)

Policy CodePolicy CS182TN.G

Change TypeDefinitions and Supporting Information updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionInclude documentation of specific qualifying criteria (e.g., MELD score, GFR, ASA class, AHI, details of procedural complexity, preoperative studies not performable outpatient, or postoperative events such as AKI or hemodynamic instability) to support inpatient admission.

POLICY UPDATE CHANGES

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

CoveredCovered with criteria

ExcludedObstetric exclusion

InterQualSupports

Coverage Summary

This policy addresses coverage of Elective Inpatient Services for Tennessee Medicaid and CoverKids members. UnitedHealthcare considers planned elective inpatient admissions medically necessary and covered with criteria when the specified medical, procedural, preoperative, or postoperative criteria are met. The policy uses InterQual as a supporting clinical tool for medical necessity and level-of-care decisions. Note: the policy excludes obstetric care during pregnancy, childbirth, and the postpartum period.

Medically Necessary Elective Inpatient Admission Criteria

A planned elective inpatient admission is considered medically necessary when ANY of the following criteria are met:

ANY of the following

Medical conditions increasing risk of major postoperative complications
- Advanced liver disease (MELD Score > 8)> 8
- Cognitive status that warrants inpatient stay
- Severe renal disease (GFR <= 30 mL/min)<= 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 risk of complications
- Anesthetic risk
  - American Society of Anesthesiologists class III or greaterASA III or greater
  - Age 85 years or older>= 85 years
  - High risk for thromboembolism
  - Moderate (AHI 15-30) to severe (AHI > 30) sleep apneaAHI 15-30 (moderate); > 30 (severe)
Preoperative or planning and monitoring needs
- The need for preoperative diagnostic studies that cannot be performed as an outpatient
- Advance surgical planning determines inpatient recovery required
  - 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
Procedural related events or postoperative conditions that require inpatient stay
- Acute Kidney Injury>= 0.3 mg/dL increase in 48 hours or >=1.5x baseline in 7 days; urine <0.5 mL/kg/hr for 6 hours; >50% reduction in eGFR
  KDIGO 2012 criteria
- Altered mental status that is severe or persistent
- Ambulatory or appropriate activity level status is not achieved
- Conversion to open or complex procedure that requires inpatient care
- Excessive drainage or bleeding from the operative site

ref

Definitions and Supporting Evidence

UnitedHealthcare uses InterQual criteria as a supporting source for medical necessity and level-of-care decisions; InterQual is intended to be used alongside the independent professional medical judgment of a qualified provider. The policy lists medical, procedural, preoperative, and postoperative factors that indicate when an elective inpatient admission is appropriate. Refer to federal, state, or contractual definitions which supersede the policy definitions when applicable. This policy specifically does not apply to obstetric members during pregnancy, childbirth, or the post‑partum period.

Referenced clinical guidance and evidence include: AHA/ACC 2024 perioperative cardiovascular guideline, AASM 2008, ASA 2020, KDIGO 2012, and GINA 2023.

Definitions

Acute Kidney Injury: Increase in serum creatinine >= 0.3 mg/dL in 48 hours OR increase >= 1.5x baseline within 7 days OR reduction >50% in eGFR OR urine volume <0.5 mL/kg/hour for 6 hours (KDIGO, 2012).>= 0.3 mg/dL in 48 hours; >=1.5x baseline in 7 days; >50% reduction in eGFR; urine <0.5 mL/kg/hr for 6 hours

Apnea Hypopnea Index (AHI): The number of apneas plus hypopneas per hour of sleep; used to define OSA severity. Severity: Mild 5-<15; Moderate 15-30; Severe >30 events/hour (AASM, 2008).Moderate 15-30 events/hour; Severe >30 events/hour

Hemodynamic Instability: Vital sign abnormality not readily corrected with treatment, e.g., systolic BP < 90 mm hg or decrease > 40 mm hg; urine output <0.5 mL/kg/hr; MAP < 65 mm hg; capillary refill > 3 seconds; altered level of consciousness; shortness of breath; persistent tachycardia.systolic BP < 90 mm hg or decrease > 40 mm hg; MAP < 65 mm hg; capillary refill > 3 seconds; urine <0.5 mL/kg/hr

ASA Physical Status Classification: American Society of Anesthesiologists Physical Status Classification System: Six-class system to categorize pre-anesthesia medical comorbidities; ASA III or greater flagged as increased anesthetic risk.ASA III or greater

Provider Actions and Prior Authorization

Documentation Required

Document medical necessity details

Include documentation of specific qualifying criteria to support inpatient admission. Examples of qualifying documentation include objective scores, test results, classification, or procedural details demonstrating increased risk or need for inpatient care.

MELD score (e.g., > 8)
GFR (e.g., ≤ 30 mL/min)
ASA class (American Society of Anesthesiologists Physical Status Classification, III or greater)
AHI (Apnea–Hypopnea Index; moderate 15–30 or severe > 30 events/hour)
Procedural complexity or details (e.g., extensive dissection, complex wound/drain management, conversion to open procedure)
Acute Kidney Injury (KDIGO criteria: ≥0.3 mg/dL creatinine increase in 48 hrs, ≥1.5× baseline in 7 days, urine <0.5 mL/kg/hr for 6 hrs, or >50% reduction in eGFR)
Hemodynamic instability (e.g., systolic BP <90 mm Hg or decrease >40 mm Hg; MAP <65 mm Hg; capillary refill >3 sec)

Prior Authorization

Prior authorization expectation (implied)

This policy is used to interpret UnitedHealthcare benefit decisions; providers should follow applicable state, federal, or plan contractual requirements and any prior authorization processes when seeking inpatient admission approval for elective procedures. In the event of conflict, federal, state, or contractual definitions and requirements supersede this policy.

Follow state/plan contractual requirements and prior authorization processes that apply to the member or service.
Obtain prior authorization/approval as required for inpatient elective admissions per the member’s plan or state Medicaid/CoverKids rules.