CurrentUnitedHealthcarePolicy CS182KS.02

Elective Inpatient Services (for Kansas Only)

Defines medical necessity criteria for planned elective inpatient admissions for surgeries or procedures for UnitedHealthcare Community Plan members in Kansas, using InterQual criteria and supplemental clinical definitions. Excludes obstetric care during pregnancy, childbirth, or postpartum.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Kansas Only)

Policy CodePolicy CS182KS.02

Change TypeDefinitions and references revised; prior version archived

Effective DateFebruary 1, 2026

Next Review Date

Key ActionApply InterQual criteria to support medical necessity and level of care decisions and document justification consistent with InterQual and professional medical judgment.

POLICY UPDATE CHANGES

Updated definitions and supporting information; previous version CS182KS.01 archived.

1State-specific policy (Kansas only)

MultipleClinical criteria categories

InterQualPrimary evidence source

Coverage Summary

Defines medical necessity criteria for planned elective inpatient admissions for surgeries or procedures for UnitedHealthcare Community Plan members in Kansas, using InterQual criteria and supplemental clinical definitions. Status: CURRENT. Subject: Elective Inpatient Services (Kansas). Coverage stance: covered_with_criteria. This policy identifies clinical and procedural risk factors, physiologic thresholds, and events that justify inpatient admission (e.g., MELD Score > 8, GFR ≤ 30 mL/min, AHI 15–30 (moderate), AHI > 30 (severe), acute kidney injury parameters). Excludes obstetric care during pregnancy, childbirth, or the post-partum period. Primary evidence source: InterQual. This is a Kansas-specific UnitedHealthcare policy (Policy Number: CS182KS.02).

MELD Score> 8

GFR<= 30 mL/min

AHI - moderate15-30 events/hour

AHI - severe> 30 events/hour

AKI - serum creatinine increase (absolute)>= 0.3 mg/dL in 48 hours

AKI - serum creatinine increase (relative)>= 1.5 times baseline within prior 7 days

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

Hemodynamic - systolic blood pressure< 90 mm hg or decrease > 40 mm hg

Hemodynamic - MAP< 65 mm hg

Hemodynamic - capillary refill> 3 seconds

Hemodynamic - oliguria goal0.5 mL/kg/hour urine output (treatment goal)

Medically Necessary Elective Inpatient Admission Criteria

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)
- Cognitive status that warrants inpatient stay
- Severe renal disease (GFR <= 30 mL/min)
- Severe valvular heart disease
- Stroke or TIA within 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 greater
  - Age 85 years or older
  - High risk for thromboembolism
  - Moderate (AHI 15-30) to severe (AHI > 30) sleep apnea
  - Persistent electrolyte abnormalities unresponsive to treatment (e.g., hyperkalemia, hyponatremia)
  - Risk of post-operative airway compromise (e.g., open neck procedure, airway surgery)
Other indications for inpatient admission
- The need for preoperative diagnostic studies that cannot be performed as an outpatient
- Advance surgical planning determines an individual requires inpatient recovery and care following a surgical procedure
  - 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 event that may require an inpatient stay
  - Acute Kidney Injury

ref

Definitions & Evidence

UnitedHealthcare applies InterQual criteria to support medical necessity and level-of-care decisions for planned elective inpatient admissions; InterQual is used alongside independent professional medical judgment. The policy is state-specific and applies only to Kansas. It explicitly excludes obstetric members during pregnancy, childbirth, and the post-partum period. The policy history notes an update to the ASA risk scoring definition and Clinical Evidence/References (archived prior version CS182KS.01).

Term	Definition
Acute Kidney Injury
Acute Kidney Injury is defined as any of the following: - Increase in the serum creatinine value of ≥ 0.3 mg/dL (26.52 micromol/L) in 48 hours - Increase in serum creatinine of ≥ 1.5 times baseline within the prior 7 days - Reduction of more than 50% in estimated glomerular filtration rate from baseline - Urine volume < 0.5 mL/kg/hour for 6 hours (KDIGO, 2012)
Apnea Hypopnea Index (AHI)
The number of apneas plus the number of hypopneas during the entire sleeping period, times 60, divided by total sleep time in minutes; unit: event per hour (AASM, 2008). Moderate AHI 15-30, Severe AHI > 30/hour.
Hemodynamic Instability
Vital sign abnormality not readily corrected by appropriate treatment as indicated by one or more of the following: a systolic blood pressure < 90 mm hg or decrease in systolic blood pressure > 40 mm hg; oliguria treatment goal of 0.5 mL/kg/hour urine output; mean arterial pressure (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 assessing pre-anesthesia systemic disease (ASA I-VI) used to categorize a patient's physiological status and help predict operative risk.

Primary criteria source: InterQual.

Guideline references: 2024 AHA/ACC/ACS perioperative cardiovascular guideline.

Guideline references: AASM 2008 (Apnea Hypopnea Index definitions).

Guideline references: ASA statements and 2014 perioperative OSA management report.

Guideline references: KDIGO 2012 (Acute Kidney Injury definition).

Guideline references: GINA 2023 (asthma perioperative considerations).

Provider Actions & Requirements

Documentation Required

Use InterQual criteria

Apply InterQual criteria as the source to support medical necessity and level-of-care decisions and document the clinical justification in the medical record consistent with InterQual and the provider’s independent professional medical judgment.

Documentation Required

Document specific clinical indicators

Document presence of qualifying clinical indicators that support inpatient admission. Include physiologic thresholds and recent events when applicable (for example: MELD score, GFR, recent stroke or TIA, ASA physical status, AHI for sleep apnea, and procedure-related factors such as complexity or conversion to open).

MELD score (threshold noted in criteria)
GFR (≤ 30 mL/min)
Stroke or TIA within the last 3 months
ASA Physical Status class (III or greater)
Apnea‑Hypopnea Index — moderate 15–30, severe >30
Procedure factors (complex approach, conversion to open, extensive/prolonged surgery)

Prior Authorization

Policy applies for Kansas members

This medical policy applies only to Kansas members. Verify applicable state plan and contract requirements and obtain any required preauthorization per UnitedHealthcare Kansas procedures before proceeding.