CurrentUnitedHealthcarePolicy CS143PA.S

Outpatient Surgical Procedures - Site of Service (for Pennsylvania Only)

Defines UnitedHealthcare Pennsylvania-specific medical necessity criteria for when planned surgical procedures performed in a hospital outpatient department are considered medically necessary (and therefore covered) versus when ambulatory surgical center (ASC) is preferred. Applies to site-of-service reviews and prior authorization determinations for outpatient procedures.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures - Site of Service (for Pennsylvania Only)

Policy CodePolicy CS143PA.S

Change TypeReferences updated

Effective DateAug 1, 2025

Next Review Date

Key ActionConduct site of service medical necessity reviews and refer to the UnitedHealthcare Community Plan Prior Authorization List for procedure codes requiring prior authorization; document the specific medical necessity criterion to support use of the hospital outpatient department.

SourceLink

POLICY UPDATE CHANGES

Updated References section to reflect the most current information.

22Listed medical necessity criteria

See PA Prior Auth ListPA prior auth list

Coverage Summary

This UnitedHealthcare policy (Policy Number CS143PA.S, effective August 1, 2025, last reviewed August 1, 2025) defines Pennsylvania-specific site-of-service medical necessity criteria for planned outpatient surgical procedures. It explains when use of a hospital outpatient department is considered medically necessary (and therefore covered) versus when an ambulatory surgical center (ASC) is the preferred/expected site, and applies to site-of-service reviews and prior authorization determinations under Pennsylvania member plans.

Medical-Necessity Criteria

Medically Necessary for Hospital Outpatient Department

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when ANY one of the following criteria are met:

Medically Necessary for Hospital Outpatient Department - top level

Advanced liver disease (MELD Score > 8)> 8
Overnight recovery: Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
Anticipated transfusion: 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)
COPD: Chronic obstructive pulmonary disease (COPD) with FEV1 < 50%< 50%
CAD or PVD: Coronary artery disease (CAD) or peripheral vascular disease (PVD) with ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug eluting stentDES within 1 year
Developmental or cognitive status: Developmental stage or cognitive status warranting use of a hospital outpatient department
End stage renal disease (receiving peritoneal or hemodialysis) with hyperkalemia above reference rangehyperkalemia above reference range
Recent CVA or TIA: History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) with recent event (< 3 months)< 3 months
Recent MI: History of myocardial infarction (MI) with recent event (< 3 months)< 3 months
Recent stent or angioplasty: 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
Requires agreement of surgeon, cardiologist, and anesthesia if antiplatelet therapy continued
Ongoing myocardial ischemia: Ongoing evidence of myocardial ischemia
Poorly controlled asthma (FEV1 < 80% despite medical management)< 80% despite medical management
Pregnancy
Prolonged surgery (> 3 hours)> 3 hours
Resistant hypertension (Poorly Controlled)
Severe valvular disease: Severe valvular heart disease
Sleep apnea: moderate to severe obstructive sleep apnea (OSA)Moderate: AHI or RDI ≥15 and ≤30; Severe: AHI or RDI >30/hr
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
Age under 18 years unless otherwise required by federal, state, or contractual requirements< 18 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:

Medically Necessary due to Inability to Access ASC - top level

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
Excludes surgeon preferred or proprietary instruments, instrument sets, or hardware sets
No ASC with necessary equipment: 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 such as duodenoscope, ureteroscope
No ASC with physician privileges:

Provider Actions

Prior Authorization

Site of Service Medical Necessity Review / Prior Authorization

Site of service medical necessity reviews will be conducted; refer to UnitedHealthcare Community Plan Prior Authorization List for procedure codes requiring prior authorization. If outpatient hospital department is not considered medically necessary, that location will not be covered under the member's plan.

See UnitedHealthcare Community Plan Prior Authorization List

Documentation Required

Document clinical criterion supporting hospital outpatient setting

Providers must document the specific medical necessity criterion (e.g., MELD score, FEV1 values, recent MI/CVA dates, anticipated transfusion need, inability to access ASC equipment or privileges) to support use of hospital outpatient department.

MELD score
FEV1 values
Recent MI or CVA dates (< 3 months)
Anticipated transfusion need or bleeding disorder requiring replacement factor/blood products
Inability to access ASC equipment (examples: fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes) or lack of physician privileges at an ASC

Denial Risk

Denial if hospital outpatient department not medically necessary

Claims for procedures in the hospital outpatient department may be denied if none of the listed medical necessity criteria or access exceptions are met.

Background

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether the outpatient hospital department is medically necessary under the member's benefit plan. The policy lists specific clinical conditions (e.g., advanced liver disease, recent MI/CVA, unstable cardiac or respiratory conditions, pregnancy, severe OSA, prolonged surgery) and access constraints (e.g., no geographically accessible ASC with necessary equipment or physician privileges, ASC-specific exclusion by health condition/weight) that warrant performance in a hospital outpatient department instead of an ASC.

Term	Definition
ASA Physical Status Classification System
The American Society of Anesthesiologists (ASA) physical status classification system: a subjective assessment of a patient's overall health based on five classes used to help predict operative risk.

References: American Society of Anesthesiologists (ASA) guidance and statements, American Academy of Sleep Medicine (AASM) OSA definitions, American Heart Association (AHA) heart failure classes, and Pennsylvania Code (Title 55, Chapter 1101) are cited as supporting sources; references accessed 2025.

OpenPayer

Outpatient Surgical Procedures - Site of Service (for Pennsylvania Only)

Coverage Summary

Medical-Necessity Criteria

Provider Actions

Coding

Background

Revision History