CurrentUnitedHealthcarePolicy CS143TN.P

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

Governs medical necessity reviews determining when planned outpatient surgical procedures performed in a hospital outpatient department (HOPD) are covered for Tennessee Medicaid and CoverKids members, including criteria requiring HOPD rather than an ambulatory surgical center (ASC).

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS143TN.P

Change TypeNon-material editorial updates

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization per the UnitedHealthcare Community Plan Prior Authorization List for procedures that require it.

SourceLink

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled Treatment of Temporomandibular Joint Disorders (for Tennessee Only).

Updated References section to reflect the most current information.

TennesseeState-specific

Aug 1, 2025Effective

MultipleClinical criteria

ReferencedPrior auth list

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical and patient-status criteria

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when ANY of the following clinical or patient-status conditions are present:

HOPD indicated if any listed clinical condition applies: Advanced liver disease (MELD Score > 8)

HOPD indicated if any listed clinical condition applies: Planned/anticipated need for overnight recovery and care following the surgical procedure

HOPD indicated if any listed clinical condition applies: Anticipated need for transfusion

HOPD indicated if any listed clinical condition applies: Bleeding disorder requiring replacement factor, blood products, or special infusion products to correct a coagulation defect

HOPD indicated if any listed clinical condition applies: Symptomatic cardiac arrhythmia despite medication

HOPD indicated if any listed clinical condition applies: Chronic obstructive pulmonary disease (COPD) with FEV1 < 50%FEV1 < 50%

HOPD indicated if any listed clinical condition applies: Coronary artery disease (CAD) or peripheral vascular disease (PVD) with ongoing ischemia or recent drug-eluting stent placement

HOPD indicated if any listed clinical condition applies: Developmental stage or cognitive status that warrants use of a hospital outpatient department

HOPD indicated if any listed clinical condition applies: End stage renal disease receiving peritoneal or hemodialysis with hyperkalemia above reference range

HOPD indicated if any listed clinical condition applies: Recent cerebrovascular accident (CVA) or transient ischemic attack (TIA) within 3 months< 3 months

HOPD indicated if any listed clinical condition applies: Recent myocardial infarction (MI) within 3 months< 3 months

HOPD indicated if any listed clinical condition applies: Recent coronary intervention: drug-eluting stent within 1 year, or bare metal stent/plain angioplasty within 90 days unless aspirin and antiplatelet therapy will be continued by agreement of surgeon, cardiologist, and anesthesiaDES ≤ 1 year; BMS/plain angioplasty ≤ 90 days

HOPD indicated if any listed clinical condition applies: Poorly controlled asthma (FEV1 < 80% despite medical management)FEV1 < 80%

HOPD indicated if any listed clinical condition applies: Pregnancy

HOPD indicated if any listed clinical condition applies: Prolonged surgery anticipated (> 3 hours)> 3 hours

HOPD indicated if any listed clinical condition applies: Resistant (poorly controlled) hypertension

HOPD indicated if any listed clinical condition applies: Severe valvular heart disease

HOPD indicated if any listed clinical condition applies: Moderate to severe obstructive sleep apnea (OSA)

HOPD indicated if any listed clinical condition applies: Uncompensated chronic heart failure (NYHA class III or IV)

HOPD indicated if any listed clinical condition applies: Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia

HOPD indicated if any listed clinical condition applies: Age under 18 years unless otherwise required by federal, state, or contractual requirements

Access and equipment criteria

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when there is inability to access an ambulatory surgical center for the procedure due to ANY one of the following:

Access/ASC capability criteria: An ASC's specific guideline regarding the individual's health conditions or weight would preclude management of the individual within an ASC

Access/ASC capability criteria: No geographically accessible ASC has the necessary equipment for the procedure (examples include but are not limited to fluoroscopy, laser, ocular equipment, operating microscope, nonstandard scopes such as duodenoscope or ureteroscope)

Access/ASC capability criteria: No geographically accessible ASC at which the individual's physician has privileges

This justification excludes surgeon-preferred or proprietary instruments, instrument sets, or hardware sets

Surgeon-preferred or proprietary instruments, instrument sets, or hardware sets are excluded as a justification for performing a planned outpatient procedure in a hospital outpatient department when claiming an ambulatory surgical center lacks necessary equipment. Facilities and providers must rely on the ASC access and equipment criteria in this policy; preference for specific proprietary tools alone does not meet the access/equipment exception.

When none of the listed clinical criteria (for example, advanced liver disease, anticipated need for overnight recovery, transfusion need, bleeding disorders, symptomatic arrhythmia, COPD with FEV1 < 50%, recent cardiac or cerebrovascular events, prolonged surgery > 3 hours, pregnancy, pediatric status, etc.) apply, and there is a geographically accessible ASC that is appropriate for the procedure and where the physician has privileges, the hospital outpatient department location is not considered medically necessary and will not be covered under the member's benefit plan.

Conversely, a single access/equipment/privilege limitation — such as an ASC's guideline excluding the individual for health or weight reasons, absence of geographically accessible ASC with the required equipment, or lack of physician privileges at available ASCs — is sufficient to justify HOPD as medically necessary.

Planned Procedures List, Clinical Thresholds, and Scores

Planned Surgical Procedures List (referenced)mixed

No codes listed

OSA severity (AHI/RDI) thresholds — mild/moderate/severe ranges

Mild OSA (AHI/RDI)AHI or RDI ≥ 5 and < 15 per AASM (2008)

Moderate OSA (AHI/RDI)AHI or RDI ≥ 15 and ≤ 30 per AASM (2008)

Severe OSA (AHI/RDI)AHI or RDI > 30 events/hour per AASM (2008)

MELD Score — threshold referenced in criteria

MELD Score thresholdMELD Score > 8 is listed as a criterion indicating need for hospital outpatient department

ContextUsed to identify advanced liver disease as sufficient to justify HOPD vs ASC

Source referencePolicy lists 'Advanced liver disease (MELD Score > 8)' in clinical criteria

FEV1 thresholds for COPD/poorly controlled asthma referenced as criteria

COPD FEV1 thresholdFEV1 < 50% identifies COPD severe enough to justify HOPD

Poorly controlled asthma FEV1 thresholdFEV1 < 80% despite medical management is listed for poorly controlled asthma

Clinical useFEV1 thresholds are clinical criteria that alone can justify HOPD when present

Recent events — CVA/TIA, MI, DES/BMS/angioplasty timing thresholds

CVA/TIA timingRecent CVA/TIA defined as a recent event within 3 months

MI timingRecent myocardial infarction defined as a recent event within 3 months

Coronary intervention timingDrug-eluting stent (DES) within 1 year; bare metal stent (BMS) or plain angioplasty within 90 days unless antiplatelet therapy continued by agreement

Prolonged surgery — duration threshold prompting HOPD (> 3 hours)

Prolonged surgery duration> 3 hours is identified as prolonged surgery warranting HOPD

ImplicationProcedure duration >3 hours is sufficient to justify hospital outpatient department rather than ASC

Placement in criteria list'Prolonged surgery (> 3 hours)' appears among clinical indications for HOPD

Prior Authorization, Documentation, and Denial Conditions

Prior Authorization

Prior Authorization Required

Certain outpatient hospital procedures require prior authorization. For the complete list of procedure codes and any code-level requirements, refer to the UnitedHealthcare Community Plan Prior Authorization List.

Refer to the UnitedHealthcare Community Plan Prior Authorization List for the state-specific codes that require prior authorization.
Prior authorization must be obtained before scheduling the procedure when the procedure is listed as requiring prior authorization on the Community Plan Prior Authorization List.

Note

None Specified

No additional provider actions are specified in this policy beyond following applicable federal, state, and contract plan requirements and obtaining prior authorization when indicated by the Community Plan Prior Authorization List.

Documentation Required

Prior Authorization and Documentation Sources

Refer to the UnitedHealthcare Community Plan Prior Authorization List for the complete set of codes that require prior authorization and for documentation guidance required to support the request.

The Community Plan Prior Authorization List includes state-specific codes and documentation requirements.
Documentation submitted with the prior authorization request should follow the guidance on the Prior Authorization List to support medical necessity determinations.

Denial Risk

Coverage Denial if HOPD Not Medically Necessary

If the outpatient hospital department (HOPD) is not medically necessary for the procedure under the member's benefit plan, the hospital outpatient site of service will not be covered; the service may be billed at the ambulatory surgical center (ASC) level if appropriate under the member's plan.

UnitedHealthcare conducts site of service medical necessity reviews to determine whether HOPD is justified under the member's benefit plan.
When HOPD is not medically necessary, billing and coverage should follow the member's benefit terms (services may be covered at ASC level if appropriate).

Key Definitions and Scoring Tools

ASA Physical Status Classification System — brief definition and use as risk scoring tool

DefinitionASA Physical Status Classification System: a subjective 5-class categorization of a patient's physiological status used to help predict operative risk (ASA, 2020)

PurposeProvides a simple clinician-assessed score of overall health to inform perioperative risk

Usage in policyReferenced as a risk scoring tool in definitions; federal/state/contractual requirements supersede definitions

Obstructive Sleep Apnea (OSA) — severity definitions by AHI/RDI

Mild OSAAHI or RDI ≥ 5 and < 15 (AASM, 2008)

Moderate OSAAHI or RDI ≥ 15 and ≤ 30 (AASM, 2008)

Severe OSAAHI or RDI > 30 events/hour (AASM, 2008)

Poorly Controlled (hypertension) — definition used in criteria

Definition used in policy'Poorly Controlled' hypertension: requiring three or more drugs to control blood pressure (Sheppard, 2017)

Policy applicationListed as 'Resistant hypertension (Poorly Controlled)' among clinical criteria that justify HOPD

Reference noteDefinitions state federal, state, and contractual requirements supersede these definitions

OpenPayer

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

When Hospital Outpatient Department (HOPD) Site is Medically Necessary

Planned Procedures List, Clinical Thresholds, and Scores

Prior Authorization, Documentation, and Denial Conditions

Policy Purpose and Scope

Key Definitions and Scoring Tools