Elective Inpatient Services – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare Commercial and Individual Exchange plans deem planned elective inpatient admissions medically necessary when specified patient-level risks (e.g., MELD >8, GFR ≤30 mL/min, recent stroke/TIA, symptomatic cardiac or pulmonary disease, altered cognition), procedure-related risks (e.g., ASA class III+, age ≥85, complex/extended surgery, airway compromise, moderate–severe OSA) or post‑procedural events (e.g., AKI, hemodynamic instability, conversion to open procedure, excessive bleeding) are present, and explicitly excludes obstetric care during pregnancy/childbirth/post‑partum (may be applied to Medicare Advantage in some cases). Coverage requires documentation that these risk factors or events justify inpatient care and adherence to the member’s specific benefit plan (which governs in conflicts) and UnitedHealthcare may use InterQual criteria for level-of-care decisions, though the policy specifies no particular forms, frequency limits, or coding lists.