UnitedHealthcare Expands Prior Auth Requirements and Site-of-Service Medical Necessity Reviews for Certain Surgeries

October 2019 ~

UnitedHealthcare (UHC) has expanded prior authorization requirements and site of service medical necessity reviews for certain surgeries in an effort to shift surgical procedures to less expensive locations. The updated outpatient surgery policy will limit the circumstances under which the insurer will pay for certain surgeries in a hospital outpatient setting.

Effective November 1, for fully insured groups in most states, UHC will only pay for a surgical procedure performed in an outpatient hospital setting if the insurer determines the site of service for the procedure is medically necessary.

As seen in the updated Utilization Review Guideline, UHC members may choose to receive surgical procedures in an ambulatory surgical center (ASC) or other locations. We are conducting site of service medical necessity reviews, however, to determine whether the outpatient hospital department is medically necessary, in accordance with the terms of the member’s benefit plan. If the outpatient hospital department is not considered medically necessary, this location will not be covered under the member’s plan.

Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria:

• Advanced liver disease (MELD Score > 8)
• Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure
• Anticipated need for transfusion
• Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect
• Brittle Diabetes
• Cardiac arrhythmia (symptomatic arrhythmia despite medication)
• Chronic obstructive pulmonary disease (COPD) (FEV1 < 3 months])
• History of myocardial infarction (MI) (recent event [< 3 months])
• Individuals with drug-eluting stents (DES) placed within one year or bare-metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesia
• Less than 19 years of age
• Ongoing evidence of myocardial ischemia
• Poorly Controlled asthma (FEV1 < 80% despite medical management)
• Pregnancy
• Prolonged surgery (> 3 hours)
• Resistant hypertension (Poorly Controlled)
• Severe valvular heart disease
• Sleep apnea (moderate to severe Obstructive Sleep Apnea (OSA)
• Uncompensated chronic heart failure (CHF) (NYHA class III or IV)

A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following:

• There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure; or
• There is no geographically accessible ambulatory surgical center available at which the individual’s physician has privileges; or
• An ASC’s specific guideline regarding the individual’s weight or health conditions that prevent the use of an ASC

Planned Surgical Procedures List

Site of service medical necessity reviews will be conducted for the following surgical procedures only when performed in an outpatient hospital setting (see Applicable Codes List).

In California, Colorado, Connecticut, New Jersey, and New York, reviews will begin for certain surgeries happening on or after December 1. This review will occur where permitted by state law and by the terms of the member’s benefit plan. Site of service medical necessity reviews do not apply to providers in Alaska, Kentucky, Massachusetts, Maryland, and Texas.

The insurer hopes that, this policy update, by encouraging patients to utilize surgery centers, in a situation where there is no medical reason for the surgery to be performed in a hospital outpatient setting, will help minimize out-of-pocket costs and improve cost efficiencies for the overall health care system, while still providing access to safe, quality health care.

Source(s): UnitedHealthcare; Becker’s Hospital Review; Modern Healthcare;