CurrentUnitedHealthcarePolicy CSNC.MP.14.05

Elective Inpatient Services (for North Carolina Only)

Defines medical necessity criteria for planned elective inpatient admissions for certain surgeries or procedures for members in North Carolina, using InterQual criteria as supporting evidence and listing clinical conditions, procedural risk factors, and post-procedural events that justify inpatient admission.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.14.05

Change TypeDefinitions and supporting information updated; previous version archived

Effective DateMar 1, 2026

Next Review Date

Key ActionDocument one or more listed medical conditions, procedure-related risk factors, or procedure-related events that justify inpatient admission, including relevant measures (e.g., MELD score, GFR, ASA class, AHI) and clinical notes.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'American Society of Anesthesiologists Physical Status Classification System Risk Scoring Tool' and updated supporting information and references.

1State-specific policy (North Carolina)

8Medical condition examples listed

8Procedure/operational risk factors listed

Coverage Summary

Scope: Elective inpatient admission criteria for planned surgeries/procedures for members in North Carolina. Status: CURRENT. Effective date: 2026-03-01. Last review: 2026-03-01.

Coverage stance: covered_with_criteria. UnitedHealthcare adopts InterQual criteria to inform medical necessity and level-of-care decisions.

Key clinical thresholds

MELD Score> 8

Glomerular Filtration Rate (GFR)≤ 30 mL/min

Apnea Hypopnea Index (AHI) - moderate15–30 events/hour

Apnea Hypopnea Index (AHI) - severe> 30 events/hour

Acute Kidney Injury - creatinine increase≥ 0.3 mg/dL in 48 hours or ≥ 1.5× baseline within 7 days

Urine output (AKI)< 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

Provider actions & authorization guidance

Documentation Required

Document clinical justification

Document presence of one or more listed medical conditions, procedure-related risk factors, or procedure-related events that justify inpatient admission; include relevant measures (e.g., MELD score, GFR, ASA class, AHI) and clinical notes.

Include MELD score, GFR, ASA class, AHI and clinical notes

Prior Authorization

Use InterQual criteria for level-of-care decisions

UnitedHealthcare uses InterQual criteria to support medical necessity and level of care decisions; providers should reference InterQual when submitting for authorization or review.

Reference InterQual when submitting for authorization or review.

Background, definitions, and evidence

UnitedHealthcare adopts InterQual criteria to inform medical necessity and level-of-care decisions for planned elective inpatient admissions.

Excludes obstetric care: This policy does not apply to an obstetric member during pregnancy, childbirth, or the post-partum period.

Primary external tool referenced: InterQual criteria to support medical necessity and level-of-care decisions.

Guideline references include perioperative cardiovascular management guidance: AHA/ACC/ACS (2024) for noncardiac surgery.

Sleep-disordered breathing reference: AASM (2008) defining Apnea Hypopnea Index (AHI) thresholds.

Renal injury guidance: KDIGO (2012) definitions for Acute Kidney Injury.

Asthma/perioperative considerations: GINA (2023) report.

Anesthesia risk classification source: ASA (2020) Physical Status Classification System.

Additional referenced materials and bibliography are listed in the policy’s references section (e.g., ASA, AASM, KDIGO, AHA/ACC/ACS).

Definitions

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

Apnea Hypopnea Index (AHI): Number of apneas plus hypopneas per hour of sleep; AHI: mild ≥5 and <15, moderate ≥15 and ≤30, severe >30 events/hour (AASM, 2008).mild ≥5 and <15; moderate ≥15 and ≤30; severe >30 events/hour

Hemodynamic Instability: Vital sign abnormality not readily corrected including systolic BP <90 mm hg or decrease >40 mm hg, oliguria (urine output goal 0.5 mL/kg/hour), MAP <65 mm hg, capillary refill >3 seconds, altered LOC, shortness of breath, persistent tachycardia.systolic BP <90 mm hg or decrease >40 mm hg; MAP <65 mm hg; capillary refill >3 seconds; oliguria

ASA Physical Status Classification: ASA classes I-VI describing increasing severity of systemic disease and operative risk (ASA I = normal healthy patient through ASA VI = declared brain-dead organ donor).ASA I-VI

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.14.05

Change TypeDefinitions and supporting information updated; previous version archived

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Elective Inpatient Services (for North Carolina Only)

Coverage Summary

Medically necessary elective inpatient admission

Exclusions / Not applicable populations

Provider actions & authorization guidance

Background, definitions, and evidence

Coding

Revision history