CurrentUnitedHealthcarePolicy CS198OH.E

Chemotherapy observation or inpatient hospitalization (Ohio)

Defines medical necessity criteria for observation or inpatient hospitalization for administration/monitoring of cancer chemotherapy for UnitedHealthcare members in Ohio age ≥18, including specific drug regimens and clinical conditions that require inpatient care; refers to OAC 5160-1-01 and InterQual for case-by-case review.

Policy Summary

PayerUnitedHealthcare

PolicyChemotherapy observation or inpatient hospitalization (Ohio)

Policy CodePolicy CS198OH.E

Change TypeRevised regimen-based inpatient criteria

Effective DateJune 1, 2026

Next Review Date

Key ActionFollow a written protocol when administering chemotherapy and use InterQual LOC: Acute Adult Hematology/Oncology modules for medical necessity determinations.

POLICY UPDATE CHANGES

Revised drug regimen requirements for an inpatient stay; removed list of applicable cancer type(s) for the listed regimens.

Removed reference link to the Medical Policy titled Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Ohio Only).

Updated Clinical Evidence and References sections to reflect the most current information.

7Explicit chemotherapy regimens listed

3Clinical conditions that require inpatient stay

1State-specific applicability (Ohio only)

Coverage Summary

Scope: This policy applies only to UnitedHealthcare members in Ohio and defines medical necessity criteria for observation or inpatient hospitalization for administration and monitoring of cancer chemotherapy in adults aged ≥18. Coverage stance: covered_with_criteria — inpatient stays are covered when specific regimen, monitoring, or clinical-condition criteria are met. The policy focuses on inpatient/observation care needed for chemotherapy administration or monitoring (including multi‑day continuous infusions, high‑dose drug administration with therapeutic drug monitoring, intra‑arterial infusions, or procedures such as TACE).

Quick policy facts

Policy numberCS198OH.E

Effective dateJune 1, 2026

Last reviewJune 1, 2026

Has material changeYes (revised regimen-specific requirements; removed cancer type list)

Explicit chemotherapy regimens listed7

State applicabilityOhio only (excludes individuals under 18)

Methotrexate serum level thresholds> 20 µmol/L at 0 hour; > 1.0 µmol/L at 24 hours; > 0.1 µmol/L at 48 hours — increase leucovorin to 50 mg IV every 6 hours until < 0.1 µmol/L