CurrentUnitedHealthcarePolicy CS182NM.C

Elective Inpatient Services (for New Mexico Only)

Defines when a planned elective inpatient admission for certain surgeries or procedures in New Mexico is medically necessary based on patient risk factors, procedure-related factors, need for preoperative studies, residential or monitoring needs, and procedural events requiring inpatient care. Excludes obstetric care during pregnancy, childbirth, or postpartum.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for New Mexico Only)

Policy CodePolicy CS182NM.C

Change TypeDefinitions and supporting information updated; prior version archived

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must document the specific medical conditions, procedural factors, preoperative studies not feasible outpatient, residential limitations, or intra/post-procedural events that meet the policy criteria to justify elective 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.

1State-specific policy (New Mexico)

10+Example medical/procedural criteria listed

ExcludedObstetric care during pregnancy/childbirth/post-partum

Coverage Summary

Scope: Defines when a planned elective inpatient admission for certain surgeries or procedures in New Mexico is medically necessary based on patient risk factors, procedure-related factors, the need for preoperative studies, residential or monitoring needs, and procedural events requiring inpatient care. The policy explicitly excludes obstetric care during pregnancy, childbirth, or the post‑partum period.

Coverage stance: Covered with criteria — elective inpatient admission is considered medically necessary when any of the policy’s listed criteria are met (examples include MELD Score > 8, GFR <= 30 mL/min, age >= 85 years, Acute Kidney Injury, etc.).

State-specific note: This medical policy applies only to members in the state of New Mexico and providers should obtain any required authorization per UnitedHealthcare New Mexico procedures.

Policy reference and dates: Policy Number CS182NM.C. Effective Date / Last Review: February 1, 2026. Archived previous policy version CS182NM.B (summary of changes dated 02/01/2026).

Quick reference thresholds

MELD Score> 8

GFR<= 30 mL/min

Age>= 85 years

AHI - moderate15-30 events/hour

AHI - severe> 30 events/hour

AKI (KDIGO) - creatinine increase>= 0.3 mg/dL in 48 hours or >= 1.5x baseline within 7 days

AKI (KDIGO) - urine outputUrine < 0.5 mL/kg/hour for 6 hours

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

Hemodynamic Instability - MAPMAP < 65 mm hg

Hemodynamic Instability - capillary refill> 3 seconds

Hemodynamic Instability - oliguria target0.5 mL/kg/hour urine output

Medical Necessity Criteria for 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
- 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 the 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); AHI > 30 (severe)
- Persistent electrolyte abnormalities unresponsive to treatment (e.g., hyperkalemia, hyponatremia)
Need for preoperative diagnostic studies or advance surgical planning
- The need for preoperative diagnostic studies that cannot be performed as an outpatient
- Advance surgical planning inpatient recovery reasons
  - Individual's residence is distant to medical facility and there is 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 that may require inpatient stay
- Acute Kidney InjuryKDIGO criteria
  See KDIGO thresholds for AKI
- 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
- Hemodynamic Instability

ref

UnitedHealthcare uses InterQual criteria as a source to support medical necessity and level-of-care decisions. Federal, state, or plan contract terms supersede this policy and should be checked before applying the policy.

Definitions and Supporting Evidence

Background: UnitedHealthcare uses InterQual criteria to support medical necessity and level-of-care decisions; InterQual is used as an aid in connection with the independent professional medical judgment of a qualified health care provider and does not constitute medical advice.

Note: Refer to applicable federal, state, or contractual requirements that may supersede definitions or coverage in this policy — in the event of a conflict, the federal, state, or contractual requirements govern.

Definitions

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

Apnea Hypopnea Index (AHI)Number of apneas plus hypopneas per hour of sleep; moderate 15-30 events/hr; severe >30 events/hr (AASM, 2008).

ASA Physical Status ClassificationSix-class system assessing pre-anesthesia comorbidities; ASA III or greater indicates severe systemic disease (ASA, 2020).

Hemodynamic InstabilityVital sign abnormality not readily corrected by treatment as indicated by one or more: systolic BP <90 mm hg or decrease >40 mm hg; MAP <65 mm hg; new capillary refill >3 seconds; oliguria (goal 0.5 ml/kg/hr); altered consciousness; shortness of breath; persistent tachycardia.

Evidence sources cited in the policy include InterQual as the primary decision-support tool for medical necessity and level-of-care determinations, and the KDIGO 2012 definition for Acute Kidney Injury, which provides diagnostic thresholds.

KDIGO AKI definition (as used in the policy): increase in serum creatinine ≥ 0.3 mg/dL in 48 hours; or ≥ 1.5× baseline within 7 days; or reduction of > 50% in eGFR from baseline; or urine volume < 0.5 mL/kg/hour for 6 hours.

Provider Actions and Authorization

Documentation Required

Document risk factors and rationale for inpatient admission

Providers must document the specific medical conditions, procedure-related risk factors, preoperative diagnostic studies that cannot be done as an outpatient, residential limitations or monitoring needs, and any intra- or post-procedural events that meet the policy criteria in order to justify an elective inpatient admission. Examples include medical conditions that increase postoperative risk (e.g., MELD > 8, GFR ≤ 30 mL/min, recent stroke/TIA, symptomatic coronary or pulmonary disease), anesthetic or procedural risk factors (e.g., ASA class III or greater, age ≥ 85, complex/extended surgery, high thromboembolism risk, moderate–severe OSA), need for preoperative studies not feasible outpatient or lack of safe temporary residence, and procedural events such as acute kidney injury, hemodynamic instability, altered mental status, conversion to open/complex procedure, excessive bleeding/drainage, or other severe complications.

Medical conditions increasing postoperative risk (MELD > 8; GFR ≤ 30 mL/min; recent stroke/TIA; symptomatic heart or lung disease)
Procedure-related risk (ASA III+; age ≥ 85; high thromboembolism risk; moderate–severe OSA; complex or prolonged surgery)
Preoperative needs or residential limitations (preoperative studies not feasible outpatient; residence distant with no appropriate temporary lodging)
Procedural events (acute kidney injury per KDIGO; hemodynamic instability; severe altered mental status; conversion to open surgery; excessive bleeding; severe procedural complications)

Prior Authorization

Policy applies for New Mexico members

This policy applies only to UnitedHealthcare members in the state of New Mexico. Providers should obtain any required prior authorization or other authorizations in accordance with UnitedHealthcare New Mexico procedures before scheduling elective inpatient admissions.