Outpatient Surgical Procedures – Site of Service – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare will only consider planned outpatient surgical procedures in a hospital outpatient department medically necessary (and therefore covered) when one or more specified clinical criteria are met (examples: MELD >8, FEV1 thresholds, recent MI/CVA or stent timelines, symptomatic arrhythmia, anticipated transfusion/bleeding disorder, moderate–severe OSA, NYHA III/IV CHF, uncontrolled diabetes with recurrent DKA/severe hypoglycemia, pregnancy, age <18, need for overnight recovery) or when an ASC cannot be accessed due to ASC health/weight exclusions, lack of necessary equipment, or absence of physician privileges; otherwise the ASC is the appropriate site and the hospital outpatient setting is not covered. Coverage is subject to member‑specific benefit plan rules (with some state/plan exceptions), may require prior authorization and medical-record documentation to verify criteria, and explicitly excludes inability-to-access claims based solely on surgeon preference or proprietary instruments.