CurrentUnitedHealthcarePolicy CS143.U

Outpatient Surgical Procedures - Site of Service

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This policy determines when a planned surgical procedure in a hospital outpatient department is medically necessary and covered versus when an ambulatory surgical center or another site should be used. It applies to UnitedHealthcare Community Plan members, subject to federal, state, and contractual requirements.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures - Site of Service

Policy CodePolicy CS143.U

Change TypeRevised

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionConsult the applicable state-specific UnitedHealthcare Community Plan Prior Authorization List before submitting certain surgical procedures performed in an outpatient hospital setting.

SourceLink

POLICY UPDATE CHANGES

A reference link to the Medical Policy titled Surgery of the Hand or Wrist was added to the policy.

The definition of Poorly Controlled Hypertension was updated to mean hypertension requiring three or more drugs to control blood pressure.

The references section was updated to reflect current supporting information.

21Clinical or patient factors supporting hospital outpatient department medical necessity

3ASC access-related circumstances supporting hospital outpatient department medical necessity

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CurrentUnitedHealthcarePolicy CS143.U

Outpatient Surgical Procedures - Site of Service

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Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures - Site of Service

Policy CodePolicy CS143.U

Change TypeRevised

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionConsult the applicable state-specific UnitedHealthcare Community Plan Prior Authorization List before submitting certain surgical procedures performed in an outpatient hospital setting.

SourceLink

POLICY UPDATE CHANGES

A reference link to the Medical Policy titled Surgery of the Hand or Wrist was added to the policy.

The definition of Poorly Controlled Hypertension was updated to mean hypertension requiring three or more drugs to control blood pressure.

The references section was updated to reflect current supporting information.

21Clinical or patient factors supporting hospital outpatient department medical necessity

3ASC access-related circumstances supporting hospital outpatient department medical necessity

Surgical duration threshold supporting hospital outpatient department medical necessity

Under 18Age criterion supporting hospital outpatient department medical necessity

11States requiring a state-specific policy or guideline

Hospital Outpatient Department Site-of-Service Criteria

Hospital outpatient department medical necessity

A planned surgical procedure performed in a hospital outpatient department is medically necessary when the individual meets any one of the following criteria.

Clinical or patient factors

Advanced liver disease is present.MELD score > 8
Overnight recovery: Advance surgical planning determines that overnight recovery and care are required following the procedure.Overnight recovery required
Transfusion: An anticipated need for transfusion exists.
Bleeding disorder: A bleeding disorder requires replacement factor, blood products, or special infusion products to correct a coagulation defect.
Cardiac arrhythmia: Symptomatic cardiac arrhythmia persists despite medication.
COPD is present with FEV1 < 50%.FEV1 < 50%
Coronary or peripheral vascular disease: Ongoing cardiac ischemia requires medical management or a drug-eluting stent was recently placed.Drug-eluting stent within 1 year when applicable
Developmental or cognitive status: Developmental stage or cognitive status warrants use of a hospital outpatient department.
End-stage renal disease: The individual has ESRD with hyperkalemia above the reference range and receives peritoneal dialysis or hemodialysis.Hyperkalemia above reference range
Recent CVA or TIA: There is a history of CVA or TIA with a recent event.< 3 months
Recent myocardial infarction: There is a history of myocardial infarction with a recent event.< 3 months
Recent coronary intervention: A drug-eluting stent was placed within 1 year, or a bare metal stent or plain angioplasty occurred within 90 days, unless aspirin and antiplatelet drugs will be continued by agreement of the surgeon, cardiologist, and anesthesia professional.Drug-eluting stent within 1 year; bare metal stent or plain angioplasty within 90 days
The stated medication-continuation exception applies.
Myocardial ischemia: Ongoing evidence of myocardial ischemia is present.
Poorly controlled asthma: Asthma is poorly controlled despite medical management.FEV1 < 80%
Pregnancy: The individual is pregnant.
Prolonged surgery: The planned surgery is prolonged.> 3 hours
Resistant hypertension: Resistant or poorly controlled hypertension is present.Requires three or more drugs to control blood pressure
Severe valvular heart disease is present.
Sleep apnea: Moderate to severe obstructive sleep apnea is present.Moderate to severe OSA
Uncompensated chronic heart failure is present.NYHA class III or IV
Uncontrolled diabetes includes recurrent diabetic ketoacidosis or severe hypoglycemia.Recurrent DKA or severe hypoglycemia
Age under 18: The individual is under 18 years of age.Under 18 years
Subject to federal, state, or contractual requirements.

Inability to access an ASC

ASC health or weight guideline: An ASC's specific guideline regarding the individual's health conditions or weight would preclude management in an ASC setting.
Required equipment unavailable: No geographically accessible ASC has the necessary equipment for the procedure.Examples: fluoroscopy, laser, ocular equipment, operating microscope, duodenoscope, ureteroscope, or other nonstandard specialized scopes
No ASC with physician privileges: No geographically accessible ASC is available at which the individual's physician has privileges.

Federal, state, or contractual requirements: Coverage is subject to federal, state, or contractual requirements that may require coverage for a specific service.

These requirements supersede conflicting standard policy terms.

An outpatient hospital department is not covered when the site of service is determined not to be medically necessary under the member’s benefit plan. Site-of-service medical necessity is assessed for planned surgical procedures when an ASC or another outpatient location may be used.

An ASC-access exception does not include surgeon-preferred or proprietary instruments, instrument sets, or hardware sets. These items do not establish that the necessary equipment is unavailable at an otherwise accessible ASC.

A planned surgical procedure performed in an outpatient hospital department is not medically necessary for site-of-service purposes when none of the policy’s qualifying clinical, patient-specific, or ASC-access criteria is met. When the hospital outpatient site is not medically necessary, that location is not covered under the member’s plan.

Clinical Factors and Thresholds

Advanced liver disease

ConditionAdvanced liver disease

ThresholdModel for End-Stage Liver Disease score > 8

Policy relevanceSupports hospital outpatient department medical necessity

Chronic obstructive pulmonary disease

ConditionChronic obstructive pulmonary disease

ThresholdFEV1 < 50%

Policy relevanceSupports hospital outpatient department medical necessity

Authorization, Documentation, and Site-of-Service Actions

Prior Authorization

Check the state-specific prior authorization list

Consult the applicable state-specific UnitedHealthcare Community Plan Prior Authorization List before scheduling or submitting the procedure. Prior authorization and site-of-service medical necessity review are required for certain surgical procedure codes performed in an outpatient hospital setting.

Documentation Required

Submit medical records supporting criteria

Submit medical records when requested to assess whether the member meets the clinical criteria for coverage. Medical records review does not guarantee coverage of the requested service.

Documentation Required

Support the hospital site-of-service rationale

Policy Scope and Purpose

This policy determines whether a hospital outpatient department is medically necessary for planned surgery when the procedure may otherwise be performed in an ambulatory surgical center or another outpatient location. Hospital-based care may be supported by the individual’s clinical risk, anticipated postoperative needs, procedure requirements, or limitations on access to an appropriately equipped and credentialed ASC.

Policy Definitions and Risk Classifications

ASA Physical Status Classification System Risk Scoring Tool

SystemAmerican Society of Anesthesiologists Physical Status Classification System

PurposeCategorizes a patient's physiological status and can help predict operative risk

StructureA subjective assessment of overall health based on six classes

Obstructive Sleep Apnea

DefinitionA sleep-related breathing disorder involving a decrease or complete halt in airflow despite ongoing effort to breathe

Moderate severityAHI or RDI of ≥ 15 and ≤ 30

Severe severity

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures - Site of Service

Policy CodePolicy CS143.U

Change TypeRevised

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionConsult the applicable state-specific UnitedHealthcare Community Plan Prior Authorization List before submitting certain surgical procedures performed in an outpatient hospital setting.

SourceLink

On This Page

Recent drug-eluting stent

InterventionDrug-eluting stent placement

TimeframePlaced within 1 year

Policy relevanceSupports hospital outpatient department medical necessity

Recent cerebrovascular accident or transient ischemic attack

EventCerebrovascular accident or transient ischemic attack

TimeframeRecent event < 3 months

Policy relevanceSupports hospital outpatient department medical necessity

Recent myocardial infarction

EventMyocardial infarction

TimeframeRecent event < 3 months

Policy relevanceSupports hospital outpatient department medical necessity

Bare metal stent or plain angioplasty

InterventionBare metal stent or plain angioplasty

TimeframePlaced or performed within 90 days

Policy relevanceSupports hospital outpatient department medical necessity

Poorly controlled asthma

ConditionPoorly controlled asthma

ThresholdFEV1 < 80% despite medical management

Policy relevanceSupports hospital outpatient department medical necessity

Prolonged surgery

Procedure characteristicProlonged surgery

Duration threshold> 3 hours

Policy relevanceSupports hospital outpatient department medical necessity

Obstructive sleep apnea

ConditionObstructive sleep apnea

Severity criterionModerate to severe OSA

Policy relevanceSupports hospital outpatient department medical necessity

Document the specific reason the hospital outpatient department is medically necessary, including applicable clinical risk, anticipated care needs, procedure duration, age or developmental status, pregnancy, or inability to access an appropriately equipped or credentialed ASC.

Denial Risk

Hospital outpatient site not medically necessary

If the outpatient hospital department is not medically necessary under the policy criteria, that site of service is not covered under the member’s benefit plan.

Denial Risk

ASC access is available

Hospital outpatient department medical necessity may not be established when an accessible ASC can manage the individual’s health conditions or weight, has the necessary equipment, or is available to the physician with privileges, unless another policy criterion is met.

Prior Authorization

Procedure is subject to site-of-service review

Site-of-service medical necessity review applies to certain surgical procedures only when performed in an outpatient hospital setting. Verify that the procedure is included on the applicable state-specific UnitedHealthcare Community Plan Prior Authorization List.

AHI or RDI of > 30/hour

Mild severityAHI or RDI of ≥ 5 and < 15

Poorly Controlled Hypertension

DefinitionHypertension requiring three or more drugs to control blood pressure

Policy terminologyAlso identified as resistant hypertension

UseIncluded as a criterion supporting hospital outpatient department medical necessity