CurrentUnitedHealthcarePolicy CS143.T

Outpatient Surgical Procedures – Site of Service – Community Plan Medical Policy

Defines medical necessity criteria for when certain planned outpatient surgical procedures should be performed in a hospital outpatient department (HOPD) rather than an ambulatory surgical center (ASC) for UnitedHealthcare Community Plan members, including patient clinical risk factors and access-related reasons. Also references that specific procedure code lists and state exceptions apply.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures – Site of Service – Community Plan Medical Policy

Policy CodePolicy CS143.T

Change TypeAdded documentation language; template update

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionConduct site-of-service medical necessity reviews for specified outpatient procedures and refer to the UnitedHealthcare Community Plan Prior Authorization List; be prepared to provide medical records documentation when requested.

SourceLink

POLICY UPDATE CHANGES

08/01/2025: Added Medical Records Documentation Used for Reviews language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess criteria but do not guarantee coverage.

04/01/2026: Template Update removed content/language pertaining to the state of Louisiana.

~1Policy applies to Community Plan members (excludes listed states)

23Clinical criteria items listed as HOPD indications

1Policy document referenced prior auth list

Coverage Summary

Defines medical necessity criteria for when certain planned outpatient surgical procedures should be performed in a hospital outpatient department (HOPD) rather than an ambulatory surgical center (ASC) for UnitedHealthcare Community Plan members, based on member clinical risk factors (for example, advanced liver disease, cardiopulmonary disease, recent MI/CVA, poorly controlled hypertension or asthma, need for transfusion, pregnancy, prolonged surgery > 3 hours, pediatric patients under 18, and others) and when there is lack of ASC access or capability (for example, no geographically accessible ASC with necessary equipment or physician privileges).

References the existence of a specific list of procedure codes that require site-of-service medical necessity review and prior authorization (see UnitedHealthcare Community Plan Prior Authorization List) and notes that state-specific exceptions apply.

Note: federal, state, or contractual requirements (including state-specific policies) and applicable laws supersede this policy; when conflicts exist, those requirements govern.

Thresholds

MELD Score> 8

COPD FEV1< 50%

Poorly controlled asthma FEV1< 80% despite medical management

Prolonged surgery duration> 3 hours

Recent CVA/TIA< 3 months

Recent MI< 3 months

DES placement windowwithin 1 year

BMS or plain angioplasty windowwithin 90 days

OSA severityModerate AHI/RDI ≥15–30; Severe AHI/RDI >30/hr

Medical-Necessity Criteria

Medically Necessary in Hospital Outpatient Department (HOPD)

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria:

ANY of the following

Advanced liver disease (MELD Score > 8)MELD Score > 8
Overnight recovery need: Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Anticipated transfusion: Anticipated need for transfusion

Provider Actions

Prior Authorization

Site-of-service medical necessity reviews and prior authorization

Site-of-service medical necessity reviews will be conducted for certain outpatient surgical procedures when performed in an outpatient hospital setting; providers must refer to the UnitedHealthcare Community Plan Prior Authorization List for the complete list of procedure codes requiring prior authorization (accessed April 21, 2025).

Check the UnitedHealthcare Community Plan Prior Authorization List for the complete list of procedure codes requiring prior authorization (accessed April 21, 2025).

Documentation Required

Medical records documentation may be required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; documentation does not guarantee coverage and federal, state, or contractual requirements govern.

Coding

Planned surgical procedures requiring site-of-service medical necessity review / prior authorizationmixed

No codes listed

Definitions

ASA Physical Status Classification System: A subjective assessment of a patient's overall health based on five classes developed by the American Society of Anesthesiologists to help predict operative risk.

Obstructive Sleep Apnea (OSA): Per the American Academy of Sleep Medicine (AASM), OSA severity is defined as: mild AHI/RDI ≥ 5 and < 15; moderate AHI/RDI ≥ 15 and ≤ 30; severe AHI/RDI > 30/hr.

Poorly Controlled (Hypertension): Requiring three or more drugs to control blood pressure.

Background

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether planned outpatient surgical procedures should be performed in a hospital outpatient department based on member clinical risk factors or lack of ASC access/capability.

State-specific exceptions exist (refer to the Application/state-specific policy list) and providers must consult the UnitedHealthcare Community Plan Prior Authorization List for the complete list of procedure codes requiring prior authorization.

Benefit coverage is determined by federal, state, or contractual requirements; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage, and applicable federal/state/contractual requirements supersede this standard policy.

Revision History

08/01/2025material_change

Added Medical Records Documentation Used for Reviews language clarifying benefit determination governed by federal/state/contractual requirements; archived previous policy version CS143.S

04/01/2026template_updateLatest

Template Update removed content/language pertaining to the state of Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures – Site of Service – Community Plan Medical Policy

Policy CodePolicy CS143.T

Change TypeAdded documentation language; template update

Effective DateAug 1, 2025

Next Review DateN/A

SourceLink

On This Page

Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect

Cardiac arrhythmia (symptomatic arrhythmia despite medication)

COPD: Chronic obstructive pulmonary disease (COPD)FEV1 < 50%

CAD or PVD: Coronary artery disease (CAD)/peripheral vascular disease (PVD) [ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stent]DES within 1 year

Developmental or cognitive: Developmental stage or cognitive status warranting use of a hospital outpatient department

End stage renal disease [(hyperkalemia above reference range) receiving peritoneal or hemodialysis]

Recent CVA or TIA: History of cerebrovascular accident (CVA) or transient ischemic attack (TIA)recent event < 3 months

Recent MI: History of myocardial infarction (MI)recent event < 3 months

Recent coronary intervention: Individuals with drug eluting stents (DES) placed within one year or bare metal stents (BMS) or plain angioplasty within 90 daysDES within 1 year; BMS or plain angioplasty within 90 days

Unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesia

Myocardial ischemia: Ongoing evidence of myocardial ischemia

Poorly controlled asthma: Poorly Controlled asthmaFEV1 < 80% despite medical management

Prolonged surgery> 3 hours

Resistant hypertension (Poorly Controlled)

Severe valvular disease: Severe valvular heart disease

Sleep apnea [moderate to severe Obstructive Sleep Apnea (OSA)]Moderate AHI/RDI ≥15–30; Severe AHI/RDI >30/hr

Definitions per AASM

Uncompensated CHF: Uncompensated chronic heart failure (CHF) (NYHA class III or IV)NYHA class III or IV

Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia

Pediatric exclusion: Under 18 years of age

Excluded unless otherwise required by federal, state, or contractual requirements

Medically Necessary in HOPD due to lack of ASC access or capability

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following:

ANY of the following

ASC guideline exclusion: An ASC's specific guideline regarding the individual's health conditions or weight that would preclude management of an individual within an ASC setting
No ASC with necessary equipment: There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure; examples include fluoroscopy, laser, ocular equipment, operating microscope, and nonstandard scopes required to perform specialized procedures (i.e., duodenoscope, ureteroscope)
Specifically excludes surgeon-preferred or proprietary instruments, instrument sets, or hardware sets
No ASC with physician privileges: There is no geographically accessible ambulatory surgical center available at which the individual's physician has privileges

Medical records may be requested to assess clinical criteria but providing records does not guarantee coverage.
Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; those requirements govern coverage decisions.