CurrentUnitedHealthcarePolicy CS143OH.C

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

Defines when outpatient hospital department location is medically necessary for planned surgical procedures in Ohio and governs site-of-service reviews and coverage determinations for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS143OH.C

Change TypeAdministrative and reference updates

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain site-of-service medical necessity review and prior authorization for listed outpatient hospital procedures per UnitedHealthcare requirements.

SourceLink

POLICY UPDATE CHANGES

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

Updated References section to reflect the most current information.

Archived previous policy version CS143OH.B.

State-specificApplies to

>20Listed clinical conditions

Prior auth requiredPlanned procedures

InterQualPrimary criteria source

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.

Medically necessary indications for hospital outpatient department site of service

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when ANY of the following clinical conditions, perioperative needs, or access issues are present:

Clinical conditions or perioperative risk: Advanced liver disease (MELD Score > 8); Cardiac arrhythmia (symptomatic despite medication); Chronic obstructive pulmonary disease (COPD) (FEV1 < 50%); Coronary artery disease (CAD)/peripheral vascular disease (PVD) with ongoing ischemia or recent revascularization (drug eluting stent within 1 year, bare metal stent or plain angioplasty within 90 days unless aspirin and antiplatelet therapy continued by agreement of surgeon, cardiologist, and anesthesia); End stage renal disease on dialysis with hyperkalemia above reference range; Recent cerebrovascular accident (CVA) or transient ischemic attack (TIA) within 3 months; Recent myocardial infarction (MI) within 3 months; Ongoing myocardial ischemia; Poorly controlled asthma (FEV1 < 80% despite management); Pregnancy; Resistant (poorly controlled) hypertension; Severe valvular heart disease; Sleep apnea (moderate to severe OSA); Uncompensated chronic heart failure (NYHA class III or IV); Uncontrolled diabetes with recurrent DKA or severe hypoglycemia; Developmental stage or cognitive status warranting hospital-level care; Age under 18 years unless federal, state, or contractual requirements dictate otherwise; Advance surgical planning determines individual requires overnight recovery and care following a surgical proceduresee thresholds

Conditions and thresholds referenced in chunks 2 and 3

Perioperative planning needs: Anticipated need for transfusion; Bleeding disorder requiring replacement factor, blood products, or special infusion products to correct a coagulation defect; Prolonged surgery (> 3 hours); Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure

From chunks 2 and 3

Access or facility limitations: An ASC's guideline regarding the individual's health conditions or weight would preclude management in an ASC; No geographically accessible ASC that has 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); No geographically accessible ASC at which the individual's physician has privileges

Equipment/access limitations exclude surgeon-preferred or proprietary instruments, instrument sets, or hardware sets (see chunk 4)

Surgeon-preferred or proprietary instruments, instrument sets, or hardware sets are not valid reasons to require that a planned procedure be performed in a hospital outpatient department rather than an ambulatory surgical center (ASC). This policy explicitly excludes proprietary or surgeon-preferred equipment as justification for choosing the hospital outpatient department site of service.

If the hospital outpatient department is chosen solely when that site of service is not considered medically necessary under the member’s benefit plan, the hospital outpatient department will not be covered. Site-of-service determinations are made in accordance with the member’s benefit terms, and coverage is denied when the outpatient hospital location is not medically necessary.

Codes, Clinical Thresholds, and Relevant Metrics

Planned Surgical Procedures Requiring Prior Authorizationmixed

No codes listed

Clinical thresholds and scales

MELD ScoreMELD > 8 is listed as an indication for hospital outpatient department

FEV1 thresholdsCOPD: FEV1 < 50% indicates need for hospital outpatient department; Poorly controlled asthma: FEV1 < 80% despite medical management

Sleep apnea (AHI/RDI)Moderate to severe OSA is listed as an indication (see OSA severity thresholds)

NYHA class for heart failureUncompensated CHF classified as NYHA class III or IV warrants hospital outpatient department

Other numeric thresholdsRecent MI or CVA/TIA within 3 months, recent DES/BMS/stent timing (DES within 1 year, BMS or angioplasty within 90 days) are specified time-based thresholds

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for planned outpatient surgical procedures listed on the UnitedHealthcare Community Plan Prior Authorization List when performed in an outpatient hospital department. Site-of-service medical necessity reviews will be conducted to determine whether the outpatient hospital department is medically necessary per the member's benefit plan. If the outpatient hospital department is not considered medically necessary under the member's plan, the location will not be covered.

Applies only to procedures performed in an outpatient hospital setting.
Prior authorization list is state-specific; confirm the member’s state and plan.

Documentation Required

Provider Action: Request Authorization

Providers must follow UnitedHealthcare instructions for requesting prior authorization and include required documentation to support site-of-service medical necessity determinations.

Use the UnitedHealthcare Community Plan Prior Authorization List to identify affected procedure codes.
Document clinical rationale if outpatient hospital setting is chosen (e.g., anticipated need for transfusion, advanced liver disease, planned overnight recovery).

Note

Provider Action: Coverage Determination Guidance

When deciding coverage, reference applicable federal, state (Ohio Administrative Code [OAC]) and contractual requirements for the member’s benefit plan, and use InterQual® as the primary medical/surgical criteria. In the event of a conflict, federal, state (OAC) or contractual requirements govern.

InterQual® is used as primary medical/surgical criteria; if applicable InterQual® criteria are not available, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines approved by the Ohio Department for Medicaid Services.
Before applying this guideline, verify the member’s federal/state/contractual benefit terms as they may differ from the standard benefit plan.

Denial Risk

Provider Action: Billing and Appeals When Outpatient Hospital Not Medically Necessary

If the outpatient hospital department is determined not to be medically necessary per the member’s benefit plan, the provider and patient should be advised that the location will not be covered and may be financially responsible. Providers should follow billing and appeal procedures in the member’s plan and submit documentation if disputing a medical necessity determination.

Explain coverage denial of the outpatient hospital setting to the patient and provide alternatives (e.g., ASC) if appropriate.
Follow the member’s plan procedures for appeals and submit supporting clinical documentation when appealing a site-of-service medical necessity decision.

Policy Background and Purpose

UnitedHealthcare assesses whether a planned surgical procedure should occur in a hospital outpatient department versus an ambulatory surgical center (ASC) by conducting site-of-service medical necessity reviews. A hospital outpatient department is considered medically necessary when specific clinical conditions, perioperative needs, or access/facility limitations are present (examples include MELD Score > 8, anticipated need for transfusion, bleeding disorders requiring replacement products, or when advance planning indicates overnight recovery).

Access or facility limitations that may justify hospital outpatient department use include the absence of a geographically accessible ASC with required equipment or no ASC at which the treating physician has privileges. However, these access limitations do not include surgeon-preferred or proprietary instruments, instrument sets, or hardware sets, which are explicitly excluded as valid reasons for hospital outpatient department site placement.

Clinical Definitions and Classifications

ASA Physical Status Classification System

DefinitionA subjective five-class system developed by the American Society of Anesthesiologists to categorize a patient's physiological status and help predict operative risk

PurposeProvides a simple categorization of overall health useful in predicting operative risk

Scale detailsASA score is based on five classes (ASA, 2020)

Obstructive Sleep Apnea (OSA) severity

Mild OSAAHI or RDI ≥ 5 and < 15

Moderate OSAAHI or RDI ≥ 15 and ≤ 30

Severe OSAAHI or RDI > 30 per hour

Poorly Controlled (hypertension)

Policy definitionPoorly Controlled hypertension is defined as requiring three or more drugs to control blood pressure

Related term usageListed among clinical conditions (resistant hypertension/poorly controlled) that may necessitate hospital outpatient department

Source referenceDefinition per Sheppard, 2017 as cited in policy

OpenPayer

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

When Outpatient Hospital Department Site of Service Is Medically Necessary

Codes, Clinical Thresholds, and Relevant Metrics

Authorization, Documentation, and Provider Responsibilities

Policy Background and Purpose

Clinical Definitions and Classifications