CurrentUnitedHealthcarePolicy CSNC.MP.011.07

Outpatient Surgical Procedures – Site of Service (for North Carolina Only)

Defines medical necessity criteria for performing planned outpatient surgical procedures in a hospital outpatient department (vs ambulatory surgical center) for UnitedHealthcare Community Plan members in North Carolina, including clinical and access-related conditions that justify hospital outpatient site of service and reference to prior authorization list.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures – Site of Service (for North Carolina Only)

Policy CodePolicy CSNC.MP.011.07

Change TypeReferences and related policy links updated

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization when the procedure code is on the UnitedHealthcare Community Plan Prior Authorization List and document the clinical indication or inability to access an ASC to justify hospital outpatient department site of service.

SourceLink

POLICY UPDATE CHANGES

08/01/2025 - Updated References section and archived previous policy version CSNC.MP.11.06.

10/01/2025 - Updated related policy reference link for Occipital Nerve Injections and Ablation.

11/01/2025 - Updated related policy reference links for Manipulation Under Anesthesia, Vertebroplasty/Kyphoplasty, and Vertebral Body Tethering.

>20Listed clinical criteria/options that justify hospital outpatient department

1State applicability (North Carolina only)

external list

Coverage Summary

Defines medical necessity criteria for performing planned outpatient surgical procedures in a hospital outpatient department (versus an ambulatory surgical center) for UnitedHealthcare Community Plan members in North Carolina only. The policy lists clinical indications (medical conditions, physiologic thresholds, and age) and access-related reasons (equipment availability, geographic access, or physician privileges) that justify hospital outpatient department site of service, and references the external UnitedHealthcare Community Plan Prior Authorization List for procedure-level prior authorization requirements.

Medical-Necessity Criteria

Medically necessary indications for planned surgical procedure in hospital outpatient department

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

Advanced liver disease (MELD Score > 8)> 8

Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure

Anticipated need for transfusion

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

Cardiac arrhythmia (symptomatic arrhythmia despite medication)

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

Coronary artery disease (CAD)/peripheral vascular disease (PVD) with ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stentDES within 1 year

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

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

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

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

Individuals with 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/angioplasty within 90 days

Ongoing evidence of myocardial ischemia

Poorly controlled asthma (FEV1 < 80% despite medical management)FEV1 < 80%

Pregnancy

Prolonged surgery (> 3 hours)> 3 hours

Resistant hypertension (Poorly Controlled)

Severe valvular heart disease

Sleep apnea (moderate to severe Obstructive Sleep Apnea (OSA))Moderate: AHI/RDI ≥15 and ≤30; Severe: AHI/RDI >30/hr

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

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

Under 21 years of age< 21 years

Medically necessary due to inability to access 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:

An ASC's specific guideline regarding the individual's health conditions or weight that would preclude management of an individual within an ASC setting

There is 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)). Note: specifically excludes surgeon preferred or proprietary instruments, instrument sets, or hardware sets.

There is no geographically accessible ambulatory surgical center available at which the individual's physician has privileges

Provider Actions & Requirements

Prior Authorization

Prior authorization for site-of-service procedures

Site of service medical necessity reviews are conducted and certain surgical procedures require prior authorization. Providers must obtain authorization when the procedure code appears on the UnitedHealthcare Community Plan Prior Authorization List.

Refer to UnitedHealthcare Community Plan Prior Authorization List (accessed April 28, 2025)

Documentation Required

Document clinical indication for hospital outpatient department

Document the specific clinical indication (one or more criteria in the policy) or the inability to access an ambulatory surgical center — including lack of necessary equipment, geographic access, or physician privileges — to justify use of a hospital outpatient department.

Coding & Policy Identifier

Policy identifiermixed

CSNC.MP.011.07

Policy Number (Outpatient Surgical Procedures - Site of Service for North Carolina Only)

Prior authorization list referencemixed

See UnitedHealthcare Community Plan Prior Authorization List (accessed April 28, 2025)

Complete list of surgical procedure codes requiring prior authorization for each state

Note: The complete list of surgical procedure codes that require prior authorization is maintained externally — providers must refer to the UnitedHealthcare Community Plan Prior Authorization List (accessed April 28, 2025) to determine which procedure codes require prior authorization for North Carolina.

Background & Definitions

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether the outpatient hospital department location is covered under a member's benefit plan. The policy identifies specific clinical conditions (for example, advanced liver disease, cardiac or pulmonary conditions, recent MI/CVA, severe valvular disease, uncontrolled diabetes, pregnancy, pediatric patients, and moderate-to-severe OSA) and access barriers (lack of ASC equipment, geographic access, or physician ASC privileges) that can justify performing a planned surgical procedure in a hospital outpatient department rather than an ambulatory surgical center.

Obstructive Sleep Apnea (OSA) severity is defined by AHI or RDI thresholds per AASM (2021): Mild = AHI/RDI ≥ 5 and < 15; Moderate = AHI/RDI ≥ 15 and ≤ 30; Severe = AHI/RDI > 30/hr.

Term	Definition
ASA Physical Status Classification System
A subjective assessment of a patient's overall health with five classes to help predict operative risk (ASA, 2020).
Obstructive Sleep Apnea (OSA)
A sleep-related breathing disorder defined by AASM; severity by AHI or RDI: Mild ≥5 and <15; Moderate ≥15 and ≤30; Severe >30/hr (AASM, 2021).
Poorly Controlled (hypertension)
Requiring three or more drugs to control blood pressure (Sheppard, 2017).

Revision History

08/01/2025revised

08/01/2025 - Updated References section and archived previous policy version CSNC.MP.11.06.

10/01/2025revised

10/01/2025 - Updated related policy reference link for Occipital Nerve Injections and Ablation.

11/01/2025revisedLatest

11/01/2025 - Updated related policy reference links for Manipulation Under Anesthesia, Vertebroplasty/Kyphoplasty, and Vertebral Body Tethering.