RetiredUnitedHealthcarePolicy CS182LA.E

Elective Inpatient Services La Cs

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries/procedures for UnitedHealthcare Community Plan members in Louisiana. Specifies clinical conditions, procedure-related risks, and perioperative events that justify inpatient admission; excludes obstetric care.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services La Cs

Policy CodePolicy CS182LA.E

Change TypeRetired (04/01/2026); Definitions revised (03/01/2026)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must document which specific medical conditions, procedure-related risk factors, advance planning reasons, or procedural events justify the elective inpatient admission per the policy criteria.

SourceLink

POLICY UPDATE CHANGES

Policy retired and Louisiana plan membership disenrolled on 04/01/2026.

Definitions updated and supporting information/clinical evidence and references updated on 03/01/2026; previous policy CS182LA.D archived.

LouisianaGeographic scope

RetiredPolicy status

Cond-criteriaCoverage stance

Coverage Summary

This Louisiana-only Elective Inpatient Services policy (Policy No. CS182LA.E) defines medical necessity criteria for planned elective inpatient admissions for certain surgeries and procedures using InterQual-supported criteria. The policy was effective 03/01/2026 and is marked Retired April 1, 2026 with Louisiana plan membership disenrolled effective 2026-04-01. The policy specifies clinical conditions, procedure-related risk factors, advance planning reasons, and perioperative events that justify inpatient admission and explicitly excludes obstetric care. Coverage stance: covered_with_criteria.

Quick Facts

MELD Score threshold> 8

GFR threshold<= 30 mL/min

AHI - moderate15-30 events/hour

AHI - severe> 30 events/hour

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

AKI - urine output< 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

Geographic scopeLouisiana-only

Policy statusRetired April 1, 2026

Coverage stanceCovered with conditional criteria (multiple clinical criteria)

Provider Actions & Requirements

Documentation Required

Document clinical justification for inpatient admission

Providers must document which specific medical conditions, procedure-related risk factors, advance planning reasons, or procedural events justify the elective inpatient admission per the policy criteria.

Prior Authorization

Policy applies to Louisiana members only

This policy applies only to members in the state of Louisiana. Before relying on this policy for coverage determinations, confirm applicability to the member's state (Louisiana) and check federal, state, or contractual benefit requirements, which govern in the event of a conflict.

Definitions & Thresholds

UnitedHealthcare uses InterQual criteria to support medical necessity and level-of-care decisions; InterQual is intended to be used with independent clinical judgment. The policy lists medical conditions, procedure-related risk factors, advance planning reasons, and procedural events that warrant inpatient admission, and notes that it does not apply to obstetric members during pregnancy, childbirth, or the post‑partum period. This policy is retired for Louisiana as of April 1, 2026.

Term	Definition
Acute Kidney Injury	Defined as any of the following: increase in serum creatinine ≥ 0.3 mg/dL in 48 hours; increase in serum creatinine ≥ 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: events per hour (AASM, 2008)
Hemodynamic Instability	Vital sign abnormality not readily corrected by appropriate treatment as indicated by one or more of the following: 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 (Sevransky, 2009)
ASA Physical Status Classification	Six-class system (I–VI) to categorize a patient's physiologic status and operative risk; a subjective assessment of overall health based on six classes (ASA I–VI) used to help predict operative risk (ASA, 2020)

Clinical Thresholds

MELD Score> 8

GFR<= 30 mL/min

AHI (moderate)15-30 events/hour

AHI (severe)> 30 events/hour

AKI - creatinine increase>= 0.3 mg/dL in 48 hours OR >= 1.5x baseline within 7 days

AKI - urine output< 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

Evidence & References

Sources referenced in this policy include: InterQual; American Academy of Sleep Medicine (AASM, 2008); American Heart Association (AHA, 1994); American Society of Anesthesiologists (ASA, 2014 and 2020 statements/guidance); Global Initiative for Asthma (GINA, 2023); KDIGO Acute Kidney Injury Guideline (2012); and the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery.

Revision History

2026-03-01definition_update

Definitions updated (including ASA Physical Status Classification System Risk Scoring Tool) and supporting information/clinical evidence and references updated; previous policy CS182LA.D archived.

2026-04-01policy_retirementLatest

Policy retired and Louisiana plan membership disenrolled; policy marked 'Retired April 1, 2026' (Policy Number CS182LA.E).