UHC Provides Helpful Guide to Surgery Admission Status

I am going to start 2026 by doing something I rarely do, and that is compliment an insurance company, and United Healthcare at that. 

As you all should know, January 1 marked the start of the second attempt by the Centers for Medicare & Medicaid Services (CMS) to eliminate the inpatient only list. And as I have noted, CMS provided little information on how to apply the case-by-case exception to be able to admit a non-inpatient only surgery patient as inpatient.

But it looks like UHC has stepped in and given us some guidance. They have published a policy on those medical conditions where they will approve inpatient admission for an elective surgery for their patients. For example, the policy lists advanced liver disease, or symptomatic lung disease, heart failure or coronary artery disease as warranting inpatient. Sleep apnea with an AHI score of 15 or greater makes the cut. It also lists an ASA score of III or greater. 

Now, let me provide a warning.

Just because a doctor documents something does not mean it is true. To quote CMS, “no presumptive weight should be assigned to the treating physician’s medical opinion.”

As we all know, just because a physician documents “I expect two midnights” does not mean that inpatient is correct, so likewise, just because a physician documents “ASA III; admit as inpatient” does not mean inpatient is appropriate. You still must look for supporting diagnoses.

Do note that this is a policy that applies to UHC’s commercial and exchange plans, but if you think about it, commercial patients are generally healthier and certainly younger than Medicare Advantage patients. So if it fits for commercial patients, it certainly should work for UHC MA patients and can serve as a general guide for all Medicare patients. 

In addition, this is not all-inclusive. There certainly can be many other conditions or combinations of conditions that are worthy of inpatient admission.

Moving on, we are all faced by an increasing number of denials of inpatient admissions. And many MA plans are making it more difficult for hospitals to fight these. In response, many hospitals use the Medicare Appointment of Representative forms to file appeals of inpatient admission denials on behalf of the patient. Well, one hospital did just that. 

But after filing the appeal, the hospital received a call from the insurance company that the patient had withdrawn their appeal. No reason was given, just a notification. Now, if you think about it, probably the only way this would have happened is if the insurer called the patient and got them to withdraw it. Did they perhaps explain to the patient that inpatient costs them more out of pocket, so why would they want to appeal to owe more money? Did they suggest the hospital is being greedy? Are the insurers now going to start doing this? It is certainly something to watch for. 

Finally, we made it through 2025, and I totally forgot Hirsch’s Heroes. So I want to recognize one now, Eileen Sullivan, the manager of denial management at Atlantic Health System in New Jersey. 

She is an experienced case manager who is absolutely a bulldog when it comes to addressing improper practices, no matter who is doing it. She takes the time to do her research, learn the regulations and the policies, and then fights one mean fight. She also advocates for the rest of us with her work with the American Case Management Association. 

We should all strive to be as persistent and ethical as Eileen.