CurrentUnitedHealthcarePolicy CS182KS.02

Medical Policy - Elective Inpatient Services (for Kansas Only)

Defines clinical criteria under which planned elective inpatient admissions for certain surgeries or procedures are considered medically necessary for UnitedHealthcare members in Kansas, using InterQual criteria as the primary evidence source. Excludes obstetric admissions during pregnancy, childbirth, and postpartum.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Policy - Elective Inpatient Services (for Kansas Only)

Policy CodePolicy CS182KS.02

Change TypeRevised definitions and referencesarchived prior version

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must document which specific criteria (medical conditions, procedure-related risks, or procedural events) are present to justify a planned elective inpatient admission per policy and InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

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

Kansas-onlyGeographic scope

InterQualPrimary criteria source

ObstetricExclusion

Coverage Summary

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UnitedHealthcare Kansas policy CS182KS.02 defines clinical criteria for when a planned elective inpatient admission for certain surgeries or procedures is considered medically necessary. The policy uses InterQual as the primary clinical criteria source to determine medical necessity and level of care decisions. The policy scope is Kansas-only and the coverage stance is covered_with_criteria. This policy lists medical, anesthetic, procedural, social, and complication-related factors that may support an inpatient admission decision for planned surgeries. Obstetric admissions are excluded — the policy does not apply to obstetric members during pregnancy, childbirth, or the postpartum period.

Key thresholds, dates & metadata (compact)

MELD Score threshold> 8

GFR threshold<= 30 mL/min

Apnea Hypopnea Index (AHI)Moderate 15-30 events/hour; Severe > 30 events/hour

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

AKI — urine output criterionUrine volume < 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

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:

Additional indications supporting inpatient admission

The need for preoperative diagnostic studies that cannot be performed as an outpatient
Advance surgical planning determines an individual requires inpatient recovery and care following a surgical procedure
Residence or social/support factors
- Individual's residence is distant to medical facility and there is a potential for urgent complications and no other nearby temporary residence is available and not appropriate for ambulatory or observation level of care
Pre- or post-operative inpatient monitoring or treatment related to need to discontinue drugs or other therapies
Procedural events or complications requiring inpatient care
- Acute Kidney Injurysee AKI definition
- Altered mental status that is severe or persistent
- Ambulatory or appropriate activity level status is not achieved
- Conversion to open or complex procedure that requires inpatient care
- Excessive drainage or bleeding from the operative site
- Hemodynamic Instabilitysee Hemodynamic Instability definition

Clarifying note: This policy explicitly does not apply to obstetric members during pregnancy, childbirth, or the post‑partum period. UnitedHealthcare relies on InterQual as the primary clinical criteria source for medical necessity and level‑of‑care determinations, and InterQual criteria are intended to be used alongside the independent professional medical judgment of a qualified health care provider.

Provider Actions & Prior Authorization

Documentation Required

Document clinical rationale for inpatient admission

Document which specific clinical criteria are present to justify a planned elective inpatient admission per this policy and InterQual criteria.

Medical conditions increasing risk of major post‑operative complications present (e.g., advanced liver disease with MELD > 8, severe renal disease with GFR ≤ 30 mL/min, recent stroke/TIA, symptomatic CAD or heart failure, unstable medical condition).
Procedure‑related risks or anesthetic factors (e.g., ASA class III or greater, age ≥85, high thromboembolism risk, moderate–severe OSA, complex or prolonged surgery).
Residence or social/support issues that preclude safe outpatient recovery.
Preoperative or intra/postoperative events requiring inpatient care (e.g., acute kidney injury, hemodynamic instability, altered mental status, conversion to open/complex procedure, excessive bleeding).

Prior Authorization

InterQual-based medical necessity determination

UnitedHealthcare uses InterQual criteria to support medical necessity and level‑of‑care decisions for elective inpatient admissions; submit supporting clinical information as InterQual review may be expected.

InterQual is the primary medical/surgical criteria source; expect InterQual review when applicable.
Provide clinical details that map to InterQual criteria (medical conditions, anesthetic risk, procedure complexity, social/support factors, and any procedural events or complications).

Background & Evidence

Background: UnitedHealthcare references InterQual criteria to determine medical necessity and level‑of‑care decisions for elective inpatient admissions. The policy identifies multiple types of factors that may support an inpatient admission decision for planned surgeries, including medical conditions that increase postoperative risk (for example, advanced liver disease, severe renal disease, symptomatic coronary disease, recent stroke), anesthetic risk factors (for example, ASA class III or greater, advanced age, high thromboembolism risk, moderate to severe sleep apnea, persistent electrolyte abnormalities), procedural or surgical complexity (for example, complex approach, complex wound care, prolonged surgery), residence or social/support factors (for example, distant residence with no appropriate nearby temporary residence), and procedural events or complications (for example, acute kidney injury, hemodynamic instability, excessive bleeding, conversion to open procedure). The policy also states it does not apply to obstetric members during pregnancy, childbirth, or the postpartum period.

Evidence: Primary clinical criteria source: InterQual.

Guideline references included: 2024 AHA/ACC/ACS et al. perioperative cardiovascular management guideline.

Guideline references included: Global Initiative for Asthma (GINA) 2023.

Guideline references included: KDIGO 2012 (Acute Kidney Injury definition).

Guideline references included: ASA 2014 perioperative management statement regarding obstructive sleep apnea.

Guideline references included: American Academy of Sleep Medicine (AASM) OSA definitions and guidance.

Additional supporting guideline material and references are cited in the policy (see policy references).

Operational Definitions

Acute Kidney Injury: Defined by KDIGO as any of: increase in serum creatinine >= 0.3 mg/dL in 48 hours; increase >=1.5x baseline within prior 7 days; reduction >50% in estimated GFR from baseline; urine volume <0.5 mL/kg/hour for 6 hours.>= 0.3 mg/dL in 48 hours; >=1.5x baseline within 7 days; >50% reduction in eGFR; urine output <0.5 mL/kg/hour for 6 hours
KDIGO, 2012
Apnea Hypopnea Index (AHI): Number of apneas plus hypopneas per hour of sleep; severity: Mild >=5 and <15; Moderate >=15 and <=30; Severe >30 events/hour.Mild >=5 and <15; Moderate 15-30 events/hour; Severe >30 events/hour
AASM, 2008
Hemodynamic Instability: Vital sign abnormality not readily corrected by treatment indicated by one or more: systolic BP <90 mm Hg or decrease >40 mm Hg; oliguria (goal 0.5 mL/kg/hour); MAP <65 mm Hg; new abnormal capillary refill >3 seconds; altered level of consciousness; shortness of breath; persistent tachycardia.