CurrentUnitedHealthcarePolicy CS182KY.07

Elective Inpatient Services Ky Cs

Defines clinical criteria under which planned elective inpatient admissions for certain surgeries or procedures are considered medically necessary for UnitedHealthcare Community Plan members in Kentucky. Excludes obstetric care during pregnancy, childbirth, and postpartum.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services Ky Cs

Policy CodePolicy CS182KY.07

Change TypeDefinitions and supporting evidence updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument and support with clinical information any of the listed medical conditions, procedure-related risk factors, need for preoperative diagnostics, advance planning rationale, or procedural events that justify inpatient admission.

SourceLink

POLICY UPDATE CHANGES

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

Definitions for Acute Kidney Injury, Hemodynamic Instability, and AHI severity included or updated.

1State-specific policy (Kentucky)

CS182KY.07Policy Version

2026-02-01Effective Date

Coverage Summary

Defines clinical criteria under which planned elective inpatient admissions for certain surgeries or procedures are considered medically necessary for UnitedHealthcare Community Plan members in Kentucky. Coverage stance: covered_with_criteria. Policy Number: CS182KY.07; Effective Date: 2026-02-01.

Key thresholds and definitions

MELD Score> 8

GFR<= 30 mL/min

AHI - moderate15-30 events/hour

AHI - severe> 30 events/hour

AKI - serum creatinine changeIncrease ≥ 0.3 mg/dL in 48 hours or ≥1.5× baseline within 7 days; urine <0.5 mL/kg/hr for 6 hours

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

Hemodynamic Instability - MAPMAP < 65 mm Hg

ExclusionThis policy excludes obstetric care (pregnancy, childbirth, post-partum)

Medically Necessary Criteria

Medically Necessary Elective Inpatient Admission - High Level

A planned elective inpatient admission for certain surgeries or procedures is considered medically necessary when ANY of the following criteria are met:

Medical conditions increasing the risk of major post-operative complications
- Advanced liver diseaseMELD Score > 8
- Cognitive status that warrants inpatient stay
- Severe renal diseaseGFR <= 30 mL/min
- Severe valvular heart disease
- Recent stroke or TIA: Stroke or TIA within last 3 monthswithin 3 months
- Symptomatic chronic lung disease (e.g., asthma, COPD)
- Symptomatic CAD or HF: 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 - ASA: Anesthetic risk: American Society of Anesthesiologists class III or greaterASA Class III or greater
  ASA Physical Status Classification System
- Age 85 years or older>= 85 years
- Thromboembolism risk: High risk for thromboembolism
- Sleep apnea severity (AHI) may require inpatient careModerate AHI 15-30 events/hour; Severe AHI > 30 events/hour
  Apnea Hypopnea Index (AHI)
Advance surgical planning determines inpatient recovery needed
- Preop diagnostics not outpatient: Need for preoperative diagnostic studies that cannot be performed as an outpatient
- Distant residence: 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/post op monitoring for therapy discontinuation: Pre- or post-operative inpatient monitoring or treatment related to need to discontinue drugs or other therapies
Procedural related event that may require an inpatient stay
- Acute Kidney Injury (AKI): Acute Kidney InjuryKDIGO: increase serum creatinine ≥ 0.3 mg/dL in 48 hours OR ≥1.5x baseline within 7 days; urine volume < 0.5 mL/kg/hour for 6 hours
  KDIGO, 2012
- Altered mental status that is severe or persistent
- Ambulatory status not achieved: Ambulatory or appropriate activity level status is not achieved
- Conversion to open/complex procedure: Conversion to open or complex procedure that requires inpatient care

ref

Provider Actions & Prior Authorization

Documentation Required

Document condition(s) meeting inpatient criteria

Document and support with clinical information any of the listed medical conditions, procedure-related risk factors, need for preoperative diagnostics, advance planning rationale, or procedural events that justify inpatient admission. Examples of supporting information include Acute Kidney Injury as defined by KDIGO (rise in serum creatinine ≥0.3 mg/dL in 48 hours or ≥1.5× baseline within 7 days; reduction >50% eGFR; urine volume <0.5 mL/kg/hr for 6 hours), evidence of hemodynamic instability (e.g., systolic BP <90 mm Hg or decrease >40 mm Hg, MAP <65 mm Hg, oliguria, altered level of consciousness, persistent tachycardia), and procedural events (e.g., conversion to open or complex procedure, excessive drainage/bleeding, airway or vascular injury).

Acute Kidney Injury (KDIGO criteria: creatinine and urine output thresholds)
Hemodynamic instability (systolic BP <90 mm Hg or decrease >40 mm Hg; MAP <65 mm Hg; oliguria; altered LOC; persistent tachycardia)
Procedure events: conversion to open/complex procedure, excessive drainage or bleeding, airway compromise, vascular injury

Prior Authorization

Prior authorization guidance

UnitedHealthcare uses InterQual as the primary medical/surgical criteria source to support medical necessity and level-of-care decisions. Providers should expect utilization review to reference InterQual when applicable and should provide documentation that addresses InterQual criteria to support an inpatient admission.

InterQual criteria will be referenced for medical necessity and level-of-care decisions

Denial Risk

Exclusion for obstetric care

This policy does not apply to an obstetric member during pregnancy, childbirth, or the post-partum period. Coverage decisions for obstetric care are governed by other applicable policies or benefit provisions.

Definitions & Evidence

UnitedHealthcare Community Plan uses InterQual as the primary evidentiary source to support medical necessity and level-of-care decisions for elective inpatient admissions. The policy lists specific patient clinical conditions, procedure-related factors, preoperative needs, and procedural events that justify inpatient admission (for example: advanced liver disease, severe renal disease, ASA class III or greater, sleep apnea severity, need for preoperative diagnostic studies that cannot be done outpatient, and events such as acute kidney injury or hemodynamic instability).

Definitions

Acute Kidney Injury (AKI) - definition: Acute Kidney InjuryIncrease in serum creatinine ≥ 0.3 mg/dL in 48 hours; or ≥1.5x baseline within 7 days; reduction >50% in eGFR from baseline; urine volume <0.5 mL/kg/hour for 6 hours

KDIGO, 2012

Apnea Hypopnea Index (AHI) - definition: Apnea Hypopnea Index (AHI)Events per hour: Moderate 15-30; Severe > 30

AASM, 2008

American Society of Anesthesiologists (ASA) - definition: American Society of Anesthesiologists Physical Status Classification SystemASA I-VI; ASA III = severe systemic disease

ASA, 2020

Hemodynamic Instability - definition: Hemodynamic InstabilitySystolic BP < 90 mm Hg or decrease > 40 mm Hg; oliguria (urine output goal 0.5 mL/kg/hour); MAP < 65 mm Hg; new abnormal capillary refill > 3 seconds; altered LOC; shortness of breath; persistent tachycardia

Sevransky, 2009

InterQual — Primary medical/surgical criteria source referenced for medical necessity and level-of-care (used by UnitedHealthcare when applicable).

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

AASM — Defines obstructive sleep apnea severity and Apnea Hypopnea Index (AHI) thresholds (moderate AHI 15–30 events/hour; severe AHI > 30 events/hour).