Commercial

Medical Policy

Notification

Level of Care for Elective Procedures (Hospital Inpatient to Hospital Outpatient Level of Care)

Notification Issued Date: 3/2/2026 12:00 PM

This version of the policy will become effective 06/01/2026.

The following new policy has been developed to communicate the Company's medically necessary criteria for when certain medically necessary elective procedures that are generally performed in an outpatient setting may be covered in an inpatient setting.

Title:

Level of Care for Elective Procedures (Hospital Inpatient to Hospital Outpatient Level of Care)

Policy #:

12.06.01

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.

There are certain diagnoses and procedures that generally do not support an inpatient admission but may be appropriate for outpatient status. However, the medical necessity determination for admission is always made on a case-by-case basis, depending on the severity of illness and intensity of service requirements. When there are multiple options for the level of care for the procedure, and in the absence of any clinical contraindication, the least intensive level of care that meets the individual's needs will be approved.

This policy applies to services rendered at acute care hospitals. The purpose is to ensure that sufficient clinical criteria have been met to assure medical appropriateness of the inpatient stay. The Company uses InterQual® Guidelines, a nationally recognized source, to assist with clinically appropriate decision-making regarding the most appropriate setting. This policy applies to procedures for which InterQual has not designated the most appropriate setting.

POLICY EXCEPTIONS

This policy does not apply to the following:

Pediatric admissions (individuals less than 18 years of age)
Behavioral health admissions
Admissions through the emergency room for urgent or emergent medical conditions
Long-term acute care inpatient admissions
Acute rehabilitation admissions

MEDICALLY NECESSARY

The elective procedures represented by one of the procedure codes in the coding section of this policy are typically performed in a hospital outpatient setting. However, a scheduled inpatient admission may be considered medically necessary, and, therefore, covered when all of the following criteria are met:

The elective procedure is considered medically necessary
Postprocedure management is reasonably expected to have a duration of 2 days or more
The individual has at least ONE of the preprocedural clinical risk factors that increase the likelihood of complications:

American Society of Anesthesiologists (ASA) Physical Status classification III or higher
Altered mental status that is severe or persistent
Cardiovascular/vascular disease

Severe valvular heart disease (e.g., rheumatic valvular disease)
Acute congestive heart failure exacerbation within 30 days of surgery

Respiratory and breathing-related conditions

Chronic obstructive pulmonary disease (COPD) with any of the following:

Functional disability from COPD
Chronic bronchodilator therapy
Forced expiratory volume in 1 second (FEV₁) < 75% of predicted

Metabolic, hepatic, or renal compromise

Uncontrolled diabetes mellitus with a diabetes-related hospitalization within the last 30 days
End-stage renal disease (ESRD) on chronic dialysis or severe renal disease (glomerular filtration rate [GFR] ≤ 30 mL/min)
Class III obesity (body mass index [BMI] ≥ 40 kg/m²)

Hematologic/immunologic

Hereditary bleeding disorder such as factor VIII, IX, or von Willebrand disease
High risk for thromboembolism with any of the following:

A need for bridging anticoagulation therapy
Stroke or transient ischemic attack within the last 3 months

Venous thromboembolism requiring anticoagulation

Within the last 3 months, or
Severe thrombophilia (defined as protein C, protein S, or antithrombin III, have homozygous factor V Leiden or prothrombin gene mutations, or have antiphospholipid antibodies)

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, inpatient admissions for medically necessary elective procedures may be covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM

The purpose of the system is to assess and communicate the individual's preanesthesia medical comorbidities and provide a guideline for the anesthesiologist/anesthetist.

ASA I: A normal, healthy individual
ASA II: An individual with mild systemic disease
ASA III: An individual with severe systemic disease
ASA IV: An individual with severe systemic disease that is a constant threat to life
ASA V: A moribund individual who is not expected to survive without the operation
ASA VI: A declared brain-dead individual whose organs are being harvested

Description

HOSPITAL OUTPATIENT SETTING

A hospital outpatient setting is defined as a setting where an individual arrives and is registered at a hospital without the need for an acute inpatient setting to undergo the procedure, and is discharged on the same date of the procedure or within the timeframe for observation. This includes on-campus outpatient setting and off-campus outpatient setting.

HOSPITAL INPATIENT SETTING

The hospital inpatient setting is defined as a setting where a higher level of care is needed based on significant impacts to the individual's safety or health with the expectation that hospital care is expected to span at least two midnights.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM

The American Society of Anesthesiologist (ASA) physical status classification system, and/or significant comorbidities may be taken into account. The ASA risk scoring system is regarded by hospitals, legal firms, accrediting bodies, and other healthcare groups as a preoperative health grading system for individuals undergoing a surgical procedure.

References

Code of Federal Regulations. Title 42, Chapter 4. Subchapter B Part 412 Subpart A § 412.3 -- Admissions. 08/19/2013 (Updated 11/25/2025). Available at: https://www.ecfr.gov/current/title-42/section-412.3 . Accessed January 9, 2026.

Code of Federal Regulations. Title 42, Chapter 4. Subchapter B Part 409 Subpart B § 409.10 – Included Services. 03/25/1983 (Updated 04/07/2000). Available at: https://www.ecfr.gov/current/title-42/section-409.10. Accessed January 9, 2026.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 6: Hospital Services Covered Under Part B. [CMS Web site]. 12/21/2023. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06.pdf. Accessed January 8, 2026

American Society of Anesthesiologists (ASA). American Society of Anesthesiologists Statement on ASA Physical Status Classification System. 2026 January. Available at: https://journals.lww.com/anesthesiologyopen/fulltext/2026/01000/american_society_of_anesthesiologists_statement_on.2.aspx. Accessed January 8, 2026.

Doherty J, Gluckman T, Hucker W, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol. 2017;69(7):871-898.

Douketis J, Spyropoulos A, Murad H, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e243.

Thompson A, Fleischmann K, Smilowitz N, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;150(19):e351-e442.

Tian Y, Allen LD, Ingram ME, et al. Disparities in Delivery of Ambulatory Surgical Care for Children. JAMA Netw Open. 2023;6(6):e2317018.

Coding

CPT Procedure Code Number(s)

11045, 15733, 15734, 15738, 15879, 21141, 21175, 21600, 27059, 27364, 27536, 27640, 27705, 27827, 32608, 33208, 33340, 36226, 37236, 37267, 37269, 37275, 37277, 42410, 43281, 43633, 43775, 44186, 47370, 49596, 49617, 49618, 50543, 50947, 50948, 51860, 54300, 55867, 57265, 57335, 58925

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revision From 12.06.01:

06/01/2026

This version of the policy will become effective 06/01/2026.

Version Effective Date:

6/1/2026

Version Issued Date:

6/1/2026

Version Reissued Date: