CurrentUnitedHealthcarePolicy CS182ID.B

Elective Inpatient Services (for Idaho Only)

Defines medical necessity criteria for planned elective inpatient admissions for surgeries/procedures for UnitedHealthcare Community Plan members in Idaho (including Idaho Medicaid Plus). Uses InterQual criteria as support and lists clinical, procedure-related, pre-/post-operative and event-driven indications warranting inpatient admission.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Idaho Only)

Policy CodePolicy CS182ID.B

Change TypeDefinitions & references updated

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument the specific medical condition(s), procedure-related risk factors, or procedural events that meet the policy's inpatient admission criteria; InterQual criteria may be used to support level-of-care decisions.

POLICY UPDATE CHANGES

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

Idaho-onlyGeographic scope

InterQualExternal criteria source

1Policy exclusions (obstetric)

Coverage Summary

Scope: Defines medical necessity criteria for planned elective inpatient admissions for surgeries and procedures for UnitedHealthcare Community Plan members in Idaho-only, including Idaho Medicaid Plus.

Key Thresholds

MELD Score> 8

GFR<= 30 mL/min

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

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

Acute Kidney Injury - serum creatinine increase>= 0.3 mg/dL in 48 hours

Acute Kidney Injury - serum creatinine multiple>= 1.5 times baseline within prior 7 days

Acute Kidney Injury - urine output< 0.5 mL/kg/hour for 6 hours

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

Hemodynamic Instability - MAP< 65 mm hg

Hemodynamic Instability - capillary refill> 3 seconds

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:

Other procedure-related factors

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title

Medically Necessary Elective Inpatient Admission Criteria

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Exclusions / Not applicable populations

Exclusions / Not applicable populations: This policy does not apply to an obstetric member during pregnancy, childbirth, or the post-partum period.

Provider Actions

Documentation Required

Support inpatient admission with clinical evidence

Document the specific medical condition(s), procedure-related risk factors, or procedural events that meet the policy's inpatient admission criteria. Indicate which of the policy criteria are met (for example: advanced liver disease with MELD > 8; severe renal disease with GFR ≤ 30 mL/min; anesthetic risk such as ASA III or greater; moderate to severe OSA with AHI ≥ 15; acute kidney injury per KDIGO thresholds; hemodynamic instability as defined in policy). InterQual criteria may be used to support level-of-care decisions. Documentation should specify the clinical findings, procedure-related risk factors, or perioperative events that satisfy the inpatient admission criteria and include pertinent objective data (scores, lab values, physiologic measurements, procedure details, timing).

InterQual criteria may be used to support level-of-care decisions.
Specify the clinical conditions, procedure-related risk factors, or procedural events (with objective data or scores) that meet the policy criteria.

Prior Authorization

Prior authorization support

Use InterQual criteria as a source to support medical necessity and level-of-care decisions when applicable. Ensure any required pre-authorization for elective inpatient admission follows Idaho state and contractual requirements for the member's plan. When submitting authorization requests, reference InterQual findings and include documentation that the case meets the policy criteria (for example relevant scores, labs, anesthetic risk, procedure complexity, or perioperative events).

Ensure pre-authorization follows Idaho state and contractual requirements for the member's plan.
Reference InterQual criteria and include supporting clinical documentation when applicable.

Definitions & Evidence

UnitedHealthcare uses InterQual criteria as a source of medical evidence to support medical necessity and level-of-care decisions; InterQual is intended to inform but not replace independent professional medical judgment.

This policy applies to the state of Idaho, including Idaho Medicaid Plus plans.

The policy focuses on clinical conditions, procedure-related risk factors (including anesthetic risk, complexity of the surgical procedure), the necessity for pre- and post-operative monitoring or treatment, and specific procedural events that may justify a planned elective inpatient admission.

InterQual criteria are referenced for determining when a planned elective inpatient admission for certain surgeries or procedures is considered medically necessary based on the outlined criteria.

Definitions

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services (for Idaho Only)

Policy CodePolicy CS182ID.B

Change TypeDefinitions & references updated

Effective DateJun 1, 2026

Next Review Date

On This Page

OpenPayer

Elective Inpatient Services (for Idaho Only)

Coverage Summary

Medically Necessary Elective Inpatient Admission Criteria

Provider Actions

Definitions & Evidence

Exclusions / Not Covered Populations

Revision History