CurrentUnitedHealthcarePolicy CS143PAS

Outpatient Surgical Procedures Site of Service (for Pennsylvania Only)

UnitedHealthcare utilization review guideline for site-of-service medical necessity determinations for planned outpatient surgical procedures performed in a hospital outpatient department in Pennsylvania. Defines conditions and circumstances under which hospital outpatient department (vs ambulatory surgical center) is considered medically necessary and therefore covered.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures Site of Service (for Pennsylvania Only)

Policy CodePolicy CS143PAS

Change TypeSupporting information and references updatedprior version archived

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument the specific clinical indications or access limitations (e.g., MELD score, recent MI/CVA dates, stent placement dates, equipment availability, ASC privileges) that meet the policy criteria to justify hospital outpatient department site of service.

SourceLink

POLICY UPDATE CHANGES

Supporting information updated and references section updated to reflect the most current information.

PennsylvaniaGeographic scope

MultipleConditional indications

Prior authOperational requirement

Coverage Summary

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This UnitedHealthcare utilization review guideline addresses site-of-service medical necessity determinations for planned outpatient surgical procedures performed in a hospital outpatient department in Pennsylvania. It defines clinical conditions and access limitations under which hospital outpatient department care (rather than an ambulatory surgical center) is considered medically necessary, and notes that federal, state, or contractual requirements supersede policy language when conflicts occur.

Key operational highlights and thresholds

Geographic scopePennsylvania-only

Operational requirementPrior authorization required for listed outpatient procedures

Site-of-service review purposeDetermine if hospital outpatient department is medically necessary vs ASC based on clinical criteria or access limitations

Documentation requirementProviders must document clinical indications or access limitations (e.g., MELD score, recent MI/CVA dates, stent placement dates, equipment availability, ASC privileges)

Use of third-party toolsUnitedHealthcare may use third-party tools (e.g., InterQual) to assist administration

Medical-Necessity Criteria

Medically Necessary Indications for Hospital Outpatient Department Site of Service

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

Medically Necessary Indications

Overnight recovery: Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Advanced liver disease (MELD Score > 8)MELD Score > 8
Anticipated transfusion: Anticipated need for transfusion
Bleeding disorder requiring replacement factor or blood products or infusion products to correct a coagulation defect
Cardiac arrhythmia (symptomatic arrhythmia despite medication)
COPD: Chronic obstructive pulmonary disease (COPD) (FEV1 50%)FEV1 50%
Text in source truncated; captures presence of COPD with specified FEV1 threshold as stated
Coronary stent: Individuals with coronary stents: drug eluting stents (DES) placed within one year or bare metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesiaDES within 1 year; BMS or angioplasty within 90 days
End stage renal disease receiving peritoneal or hemodialysis (hyperkalemia above reference range noted in source)
Developmental or cognitive: Developmental stage or cognitive status warranting use of a hospital outpatient department
Recent CVA/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
Myocardial ischemia: Ongoing evidence of myocardial ischemia
Pregnancy
Poorly controlled asthma (FEV1 80% despite medical management)FEV1 80% despite medical management
Prolonged surgery (> 3 hours)> 3 hours
Severe valvular disease: Severe valvular heart disease
Resistant hypertension (Poorly Controlled)requiring three or more drugs to control blood pressure
Poorly controlled defined in Definitions as requiring three or more drugs to control blood pressure
Sleep apnea: moderate to severe obstructive sleep apnea (OSA)Moderate: AHI/RDI ≥15 and <30; Severe: AHI/RDI >30/hr
Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia
Uncompensated CHF: Uncompensated chronic heart failure (CHF) (NYHA class III or IV)NYHA class III or IV
Pediatric: Under 18 years of age unless otherwise required by federal, state, or contractual requirements

Medically Necessary Due to Inability to Access an ASC

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:

Inability to access ASC

No ASC with necessary equipment: No geographically accessible ambulatory surgical center that has the necessary equipment for the procedure (examples include but are not limited to 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
ASC guideline excludes patient: 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 physician privileges: There is no geographically accessible ambulatory surgical center available at which the individual's physician has privileges

Provider Actions

Prior Authorization

Site-of-service medical necessity review / prior authorization required for certain outpatient procedures

Site-of-service medical necessity reviews will be conducted for certain surgical procedures when performed in an outpatient hospital setting; for the complete list of surgical procedure codes requiring prior authorization for each state, refer to the policy or state-specific lists (Pennsylvania).

Prior authorization applies to certain outpatient surgical procedure codes; see the Pennsylvania-specific lists for codes/requirements.

Documentation Required

Document clinical criteria supporting hospital outpatient necessity

Providers must document the specific clinical indication(s) or access limitations that meet the policy criteria to justify hospital outpatient department site of service. Examples of information to document include MELD score, dates of recent myocardial infarction or cerebrovascular accident, dates of coronary stent placement, availability of necessary equipment, and whether the physician has privileges at an ASC.

MELD score (threshold in policy: > 8)
Date of recent MI or CVA/TIA (policy cites recent events < 3 months)
Date of coronary stent placement (DES within 1 year; BMS or plain angioplasty within 90 days)
Documentation of necessary equipment availability (e.g., fluoroscopy, laser, operating microscope, nonstandard scopes)
Evidence of ASC privileges or lack thereof

Definitions & Thresholds

ASA Physical Status Classification System: The American Society of Anesthesiologists' subjective assessment of a patient’s overall health based on five classes, used to help predict operative risk.

Obstructive Sleep Apnea (OSA): A sleep-related breathing disorder with decreased or halted airflow despite effort; severity per AASM: Moderate: AHI/RDI ≥ 15 and < 30; Severe: AHI/RDI > 30/hr.

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

Named thresholds

MELD Score> 8

Coronary stent window - DESwithin 1 year

Coronary stent window - BMS or plain angioplastywithin 90 days

Recent CVA/TIA< 3 months

Recent MI< 3 months

Prolonged surgery duration> 3 hours

Uncompensated CHF (NYHA)Class III or IV

Poorly controlled asthmaFEV1 80% despite medical management

COPD thresholdFEV1 50% (documented in source)

Resistant (poorly controlled) hypertensionRequiring three or more drugs to control blood pressure

OSA severity - moderateAHI or RDI ≥ 15 and < 30

OSA severity - severeAHI or RDI > 30/hr

CS143PAS	Policy Number (Pennsylvania specific)
CS143PAR	Archived previous policy version referenced in history

OpenPayer

Outpatient Surgical Procedures Site of Service (for Pennsylvania Only)

Coverage Summary

Medical-Necessity Criteria

Provider Actions

Coding

Definitions & Thresholds

Revision History