ModifiedUnitedHealthcarePolicy CS182TN.G

Elective Inpatient Services Tn Cs

This UnitedHealthcare Tennessee Medical Policy defines clinical criteria under which planned elective inpatient admissions for certain surgeries or procedures are considered medically necessary for Medicaid and CoverKids members in Tennessee. It lists patient risk factors, procedure-related factors, preoperative needs, and procedural events that justify inpatient admission, and includes definitions and references.

Policy Summary

PayerUnitedHealthcare

PolicyElective Inpatient Services Tn Cs

Policy CodePolicy CS182TN.G

Change TypeDefinitions and references updated (02/01/2026)

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must document which specific medical condition(s), procedure-related factor(s), preoperative need, or procedural event from the policy criteria justify the elective inpatient admission in the medical record and authorization request.

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 (Tennessee)

CS182TN.GCurrent policy version

>12Listed clinical criteria items

Coverage Summary

This Tennessee-specific UnitedHealthcare Medical Policy (Policy Number: CS182TN.G) defines clinical criteria under which planned elective inpatient admissions for certain surgeries or procedures are covered with criteria. The policy uses InterQual criteria to support medical necessity and level-of-care decisions and lists patient risk factors, procedure-related factors, preoperative needs, and procedural events that justify inpatient admission for Medicaid and CoverKids members in Tennessee.

Status: MODIFIED. Effective Date: February 1, 2026. Last Review: February 1, 2026.

Key clinical thresholds

MELD Score> 8

GFR<= 30 mL/min

Stroke/TIA timeframeWithin last 3 months

Age>= 85 years

AHI - Moderate15-30 events/hour

AHI - Severe> 30 events/hour

AKI - creatinine deltaIncrease in serum creatinine >= 0.3 mg/dL in 48 hours OR >= 1.5x baseline within prior 7 days OR urine volume < 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 Criteria — Planned Elective Inpatient Admission

Medically Necessary: Planned Elective Inpatient Admission

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

ANY of the following

Procedure related factors that may increase the risk of complications
- Advanced liver disease (MELD Score > 8)MELD Score > 8
- Cognitive status that warrants inpatient stay
- Severe renal disease (GFR <= 30 mL/min)GFR <= 30 mL/min
- Severe valvular heart disease
- Stroke or TIA within last 3 monthsStroke/TIA within last 3 months
- Symptomatic chronic lung disease (e.g., asthma, COPD)
- 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
- American Society of Anesthesiologists class III or greaterASA III or greater
- Age 85 years or olderAge >= 85 years
- High risk for thromboembolism
- Moderate (AHI 15-30) to severe (AHI > 30) sleep apneaAHI 15-30 (moderate); AHI > 30 (severe)
- Persistent electrolyte abnormalities unresponsive to treatment (e.g., hyperkalemia, hyponatremia)
Procedure related factors that may increase the risk of complications
- Complex surgical approach (e.g., unusually extensive dissection needed)
- Complex post-operative wound care (e.g., complex drain management, open wound, previous local tissue injury resulting from factors such as radiation, previous surgery, impaired circulation, sustained pressure)
- Difficult approach because of previous operation
- Extensive or prolonged (longer than the usual time frame) surgery

Provider Actions & Authorization

Documentation Required

Document clinical criteria supporting inpatient admission

Document in the medical record and in any authorization request which specific medical condition(s), procedure-related factor(s), preoperative need, or procedural event from the policy criteria justify the planned elective inpatient admission. Specify which of the listed patient risk factors (for example advanced liver disease, severe renal disease, recent stroke/TIA, symptomatic cardiac or pulmonary disease, unstable medical condition), anesthetic or procedural risk factors (for example ASA class III+, advanced age, high thromboembolism risk, moderate-to-severe OSA, persistent electrolyte abnormalities, complex surgical approach, extensive or prolonged surgery), preoperative needs (for example inability to complete required diagnostic testing as an outpatient, need for inpatient monitoring because of therapy discontinuation), or procedural events/complications (for example acute kidney injury, altered mental status, hemodynamic instability, conversion to open surgery, excessive bleeding, severe procedure-related complication) apply to the individual case and how they support inpatient level of care.

Specific medical condition(s) from the policy (e.g., advanced liver disease, GFR ≤ 30 mL/min, recent stroke/TIA)
Anesthetic or patient-level risk factors (e.g., ASA III+, age ≥85, moderate–severe OSA, high thromboembolism risk)
Procedure-related complexity or expected postoperative needs (e.g., complex dissection, prolonged surgery, complex wound/drain management)
Preoperative or discharge planning needs (e.g., required inpatient diagnostic studies, distant residence without safe alternative)
Procedural events or complications necessitating admission (e.g., acute kidney injury, hemodynamic instability, conversion to open procedure, significant bleeding)

Prior Authorization

Prior authorization may be required per payer rules

UnitedHealthcare references InterQual criteria to support medical necessity and level-of-care decisions. When a planned inpatient admission is being considered, providers should follow payer procedures for obtaining prior authorization for UnitedHealthcare Tennessee Medicaid/CoverKids as required by the member's benefit plan and state program rules.

Policy identifier: CS182TN.G

Background and Evidence

UnitedHealthcare references InterQual criteria to support medical necessity and level-of-care decisions. The policy lists patient-level factors (for example: Advanced liver disease (MELD Score > 8), Severe renal disease (GFR <= 30 mL/min), Stroke or TIA within last 3 months, symptomatic chronic lung disease, symptomatic coronary artery disease or heart failure, unstable medical conditions, and cognitive status), procedure-level and anesthetic risk factors (for example: ASA class III or greater, Age >= 85 years, high risk for thromboembolism, and Moderate (AHI 15-30) to severe (AHI > 30) sleep apnea), and procedure complexity factors (for example: complex surgical approach, complex wound care, difficult approach due to prior operations, extensive or prolonged surgery). The policy also lists preoperative needs and procedural events that warrant inpatient admission (for example: need for preoperative diagnostic studies not available outpatient; distant residence with no appropriate nearby temporary residence; acute kidney injury; hemodynamic instability; conversion to open or complex procedure; excessive drainage/bleeding; altered mental status; prolonged monitoring needs; pain/fever/vomiting not appropriate for ambulatory care). Note: the policy does not apply to obstetric members during pregnancy, childbirth, or the post‑partum period.

Guideline references cited include: AHA/ACC/ACS 2024 perioperative cardiovascular guideline; ASA 2014 practice guidelines on perioperative management of patients with obstructive sleep apnea; KDIGO 2012 acute kidney injury guideline; GINA 2023; and AASM 2008.