CurrentUnitedHealthcarePolicy MP.11.26

Outpatient Surgical Procedures - Site of Service

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures - Site of Service

Policy CodePolicy MP.11.26

Change TypeTemplate update; shared policy creation; code list update

Effective DateJan 1, 2026

Next Review Date

Key ActionUnitedHealthcare will conduct site of service medical necessity reviews; if the outpatient hospital department is not considered medically necessary the hospital outpatient location will not be covered under the member's plan.

SourceLink

POLICY UPDATE CHANGES

Template Update and creation of shared policy version to support application to Oxford plan membership; added language excluding Massachusetts from Individual Exchange application.

22Listed clinical criteria for hospital outpatient necessity

MP.11.26Policy number

2026-01-01Effective date

Coverage Summary

Defines medical necessity criteria for performing planned surgical procedures in a hospital outpatient department (site of service) versus an ambulatory surgical center (ASC) for UnitedHealthcare Commercial and Individual Exchange plans (with state exceptions). Lists clinical conditions and access reasons that make the outpatient hospital setting medically necessary, including but not limited to advanced liver disease (MELD Score > 8), anticipated need for transfusion, bleeding disorders requiring replacement factor or blood products, symptomatic cardiac arrhythmia despite medication, COPD (FEV1 < 50%), ongoing cardiac ischemia or recent coronary interventions, developmental or cognitive considerations, dialysis-dependent end stage renal disease, recent CVA/TIA or MI (< 3 months), recent drug eluting stent (within 1 year) or bare metal stent/angioplasty (within 90 days) considerations, poorly controlled asthma (FEV1 < 80% despite medical management), pregnancy, prolonged surgery (> 3 hours), resistant/poorly controlled hypertension, severe valvular heart disease, moderate to severe OSA, uncompensated CHF (NYHA III/IV), uncontrolled diabetes with recurrent DKA or severe hypoglycemia, and age under 18. Also includes criteria allowing hospital outpatient use when an ASC is inaccessible or lacks necessary equipment, or when the physician lacks privileges at an ASC.

Benefit coverage is governed by the member's specific benefit plan and applicable laws; medical records documentation may be required to assess whether the member meets the clinical criteria for coverage. UnitedHealthcare conducts site-of-service medical necessity reviews and if the hospital outpatient department is not considered medically necessary the location will not be covered under the member's plan. Note that Individual Exchange application excludes certain states (for example, Massachusetts), per policy language and updates.

MELD Score> 8

FEV1 (COPD)< 50%

FEV1 (Poorly controlled asthma)< 80% despite medical management

Recent CVA/TIA< 3 months

Recent MI< 3 months

Drug eluting stent (DES) placedwithin 1 year

Bare metal stent (BMS) or plain angioplastywithin 90 days

Prolonged surgery> 3 hours

Severe OSAAHI or RDI > 30/hr

Medical-Necessity Criteria

Medically necessary indications for hospital outpatient department site of service

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria:

ANY of the following

Advanced liver disease (MELD Score > 8)> 8
Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Anticipated need for transfusion
Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect
Cardiac arrhythmia (symptomatic arrhythmia despite medication)
Chronic obstructive pulmonary disease (COPD) (FEV1 < 50%)FEV1 < 50%
Coronary artery disease (CAD)/peripheral vascular disease (PVD) [ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stent]DES within 1 year
Developmental stage or cognitive status warranting use of a hospital outpatient department
End stage renal disease [(hyperkalemia above reference range) receiving peritoneal or hemodialysis]
History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) [recent event (< 3 months)]< 3 months
History of myocardial infarction (MI) [recent event (< 3 months)]< 3 months
Individuals with drug eluting stents (DES) placed within one year or bare metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesiaDES within 1 year; BMS or plain angioplasty within 90 days
Ongoing evidence of myocardial ischemia
Poorly controlled asthma (FEV1 < 80% despite medical management)FEV1 < 80%
Pregnancy
Prolonged surgery (> 3 hours)> 3 hours
Resistant hypertension (Poorly Controlled)
Severe valvular heart disease
Sleep apnea [moderate to severe Obstructive Sleep Apnea (OSA)]AHI or RDI > 30/hr for severe
Uncompensated chronic heart failure (CHF) (NYHA class III or IV)NYHA class III or IV
Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia
Under 18 years of age

Medically necessary when ASC inaccessible or inappropriate

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to any one of the following:

ANY of the following

An ASC's specific guideline regarding the individual's health conditions or weight that would preclude management of an individual within an ASC setting
There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure
Examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, and nonstandard scopes required to perform specialized procedures (i.e., duodenoscope, ureteroscope)
There is no geographically accessible ambulatory surgical center available at which the individual's physician has privileges

Provider Actions

Prior Authorization

Site-of-service medical necessity review

UnitedHealthcare will conduct site-of-service medical necessity reviews to determine whether an outpatient hospital department is medically necessary; if the outpatient hospital location is not considered medically necessary, that hospital outpatient location will not be covered under the member's plan.

Documentation Required

Medical records required for review

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage. Documentation should support the specific clinical criteria listed in the policy (for example: MELD score, dates of recent MI or CVA/TIA, FEV1 values for COPD or asthma, OSA severity by AHI/RDI, and dialysis status).

Billing Rule

Applicable CPT/HCPCS code lists referenced

Refer to UnitedHealthcare’s code lists for applicable procedure codes. For Commercial plans use the Outpatient Surgical Procedures - Site of Service: CPT/HCPCS Code List; for Individual Exchange plans use the UHCProvider.com Exchange Plans Advanced Notification/Prior Authorization Requirements lists. Listing of codes in these reference lists does not guarantee coverage — the member specific benefit plan governs coverage and payment.

Outpatient Surgical Procedures - Site of Service: CPT/HCPCS Code List (Commercial Plans)
UHCProvider.com > Exchange Plans Advanced Notification/Prior Authorization Requirements (Individual Exchange)

Background

UnitedHealthcare performs site-of-service reviews to determine whether outpatient hospital department use is medically necessary versus ambulatory surgical center for Commercial and most Individual Exchange plans. Benefit coverage is governed by the member's specific benefit plan and applicable laws; medical records may be required to document criteria.

If the outpatient hospital department is not considered medically necessary, the hospital outpatient location will not be covered under the member's plan. Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and should support criteria such as MELD score, recent MI/CVA dates, FEV1 values, OSA severity, and dialysis status.

State exceptions apply for Individual Exchange plans — this Medical Policy does not apply to certain states (for example, Massachusetts) as noted in the policy updates.

OpenPayer

Outpatient Surgical Procedures - Site of Service

Coverage Summary

Medical-Necessity Criteria

Provider Actions

Definitions

Coding

Background

Revision History