CurrentUnitedHealthcarePolicy CS143TN.P

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

Defines medical necessity for performing planned outpatient surgical procedures in a hospital outpatient department versus an ambulatory surgical center for UnitedHealthcare Medicaid and CoverKids members in Tennessee.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS143TN.P

Change TypeReferences updatedminor removals

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization when a specified outpatient surgical procedure requires it per the UnitedHealthcare Community Plan Prior Authorization List.

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.

~20+listed clinical conditions/criteria that may justify hospital outpatient setting

3 hourssurgery duration threshold cited as reason for hospital outpatient department

MELD > 8advanced liver disease threshold listed

ASA referenceduses ASA Physical Status Classification in definitions

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.

Medical Necessity — Site of Service for Outpatient Surgical Procedures

Clinical necessity criteria

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary when ANY of the following clinical conditions apply:

Clinical conditions: Advanced liver disease (MELD Score > 8)MELD Score > 8

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

Clinical conditions: Anticipated need for transfusion

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

Clinical conditions: Cardiac arrhythmia: symptomatic arrhythmia despite medication

Clinical conditions: Chronic obstructive pulmonary disease (COPD) with FEV1 < 50%FEV1 < 50%

Clinical conditions: Coronary artery disease (CAD) or peripheral vascular disease (PVD) with ongoing ischemia requiring medical management

Clinical conditions: Recent coronary stent: drug eluting stent within 1 year, or bare metal stent (BMS) or plain angioplasty within 90 days unless aspirin and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesiaDES within 1 year; BMS/angioplasty within 90 days

Continued antiplatelet therapy should be by agreement of surgeon, cardiologist, and anesthesia

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

Clinical conditions: End stage renal disease receiving peritoneal or hemodialysis with hyperkalemia above reference rangehyperkalemia above reference range

Clinical conditions: Recent cerebrovascular accident (CVA) or transient ischemic attack (TIA) within 3 months< 3 months

Clinical conditions: Recent myocardial infarction (MI) within 3 months< 3 months

Clinical conditions: Poorly controlled asthma with FEV1 < 80% despite medical managementFEV1 < 80%

Clinical conditions: Pregnancy

Clinical conditions: Prolonged surgery anticipated (> 3 hours)> 3 hours

Clinical conditions: Resistant (poorly controlled) hypertension

Clinical conditions: Severe valvular heart disease

Clinical conditions: Moderate to severe obstructive sleep apnea (OSA)moderate to severe OSA

Clinical conditions: Uncompensated chronic heart failure (CHF), NYHA class III or IVNYHA III or IV

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

Clinical conditions: Age under 18 years unless otherwise required by federal, state, or contractual requirements< 18 years

Access and ASC capability criteria

A planned surgical procedure is also considered medically necessary in a hospital outpatient department when ANY of the following access or capability limitations prevent safe care in an ASC:

Access or capability limitations: An ASC's specific guideline regarding the individual's health conditions or weight would preclude management of the individual in an ASC setting

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

Access or capability limitations: No geographically accessible ASC at which the individual's performing physician has privileges

The policy explicitly excludes surgeon-preferred or proprietary instruments, instrument sets, or hardware sets as justification for performing a planned surgical procedure in a hospital outpatient department. Availability of specialized equipment at an ASC (for example, fluoroscopy, laser, ocular equipment, operating microscope, or nonstandard scopes) may justify hospital outpatient care, but preference for proprietary tools or instrument sets alone does not constitute medical necessity for the hospital outpatient setting.

If the outpatient hospital department is not considered medically necessary under the member's benefit plan, UnitedHealthcare will not cover the outpatient hospital location. Site-of-service determinations follow the terms of the member's benefit plan; when medical necessity is not met for the hospital outpatient department, claims should be denied or routed according to the plan’s coverage rules.

Procedure Codes, Prior Authorization, and Clinical Thresholds

Procedures requiring prior authorizationmixed

No codes listed

Clinical thresholds cited

MELD scoreAdvanced liver disease with MELD Score > 8

Pulmonary function (COPD)COPD with FEV1 < 50%

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

Recent cardiac eventsRecent myocardial infarction (MI) or cerebrovascular accident (CVA)/transient ischemic attack (TIA) within 3 months

Coronary stent timingDrug-eluting stent (DES) placed within 1 year; bare metal stent (BMS) or plain angioplasty within 90 days unless aspirin and antiplatelet therapy will be continued by agreement of surgeon, cardiologist, and anesthesia

Surgery durationProlonged surgery > 3 hours

Prior Authorization, Documentation, and Coverage Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for the surgical procedures specified on the UnitedHealthcare Community Plan Prior Authorization List when performed in an outpatient hospital department. Providers must check the Prior Authorization List for state-specific codes and submit an authorization request before scheduling these services.

See UnitedHealthcare Community Plan Prior Authorization List for the complete, state-specific procedure code list.

Documentation Required

Documentation Required with Prior Authorization

Providers must supply supporting clinical documentation with prior authorization requests to demonstrate the medical necessity of the requested outpatient hospital department setting. Documentation should address relevant clinical criteria (for example: MELD score, need for overnight recovery, anticipated transfusion, bleeding disorder requiring replacement products, symptomatic arrhythmia despite medication, COPD with FEV1 < 50%).

Include operative plan, anesthesia risk assessment, anticipated post-operative care needs, and any specialty-specific rationale for hospital-level resources.

Background and Scope

Selection of site of service (ASC versus hospital outpatient department) should be based on the patient’s clinical complexity, anticipated perioperative needs, and the ASC’s available resources and physician privileges. Clinical factors that favor the hospital outpatient setting include, for example, advanced liver disease (MELD Score > 8), anticipated need for overnight recovery or transfusion, bleeding disorders requiring replacement factor or blood products, symptomatic cardiac arrhythmia despite medication, and pulmonary compromise such as COPD with FEV1 < 50%.

Operational considerations that influence choice of setting include anticipated procedures or equipment needs that an ASC cannot safely provide (for example, lack of fluoroscopy, laser, operating microscope, or specialized scopes) or absence of an ASC where the performing physician has privileges. Note that equipment or access limitations may justify hospital outpatient care, but surgeon-preferred proprietary instruments or instrument sets do not justify choosing the hospital outpatient department.

Clinical Definitions and Scoring Systems

ASA Physical Status Classification System

PurposeSubjective five-class system to categorize a patient’s physiological status to help predict operative risk

OriginAmerican Society of Anesthesiologists (ASA)

StructureFive classes (ASA I through ASA V) providing a simple risk categorization

UseHelpful for preoperative risk assessment and site-of-service decision making

Obstructive Sleep Apnea (OSA) severity

Mild OSAApnea-hypopnea index (AHI) or respiratory disturbance index (RDI) ≥ 5 and < 15 events/hour

Moderate OSA

Policy Changes and Document History

2025-08-01revisionLatest

Removed reference link to the Medical Policy titled 'Treatment of Temporomandibular Joint Disorders (for Tennessee Only)' and updated the References section to reflect current information; archived previous policy version CS143TN.O.