Aetna considers inpatient hospital admission on days prior to surgery medically necessary when any of the following criteria is met:

• A cardiac catheterization or a major surgical procedure scheduled within 24 hours for a child less than 1 year of age which requires intravenous fluids to achieve and maintain adequate hydration prior to the procedure; or
• A planned major surgical procedure which requires an extensive bowel preparation (GoLytely, laxatives, multiple enemas) in a member with a co-morbidity (e.g., chronic renal failure, elderly individual with muscle wasting and poor nutritional status resulting in a significant weight loss of greater than 10 %) whose condition places the individual at high-risk for electrolyte and fluid imbalances; or
• A planned surgical procedure on partially obstructed bowel which requires a slow but extensive bowel preparation pre-operatively; or
• An invasive diagnostic procedure (e.g., aortogram, arteriogram or cardiac catheterization, myelogram) with major surgery scheduled for the following day; or
• Close monitoring of blood sugars is required to provide adequate adjustment of regular insulin coverage in preparation for an operative procedure in a brittle insulin-dependent diabetic member (i.e., diabetic individuals who experience large, unpredictable changes in blood glucose, within short periods of time, as a result of very small deviations from schedule); or
• Placement of fiducials (small screws) prior to stereotactic brain surgery; or
• The member has a concurrent medical problem that requires specific inpatient treatment prior to major surgery (defined as craniotomy, laparotomy, median sternotomy, or thoracotomy) to reduce the operative risk or assure a more favorable outcome; or
• The member is scheduled for an open heart procedure requiring cardiopulmonary bypass (cardiac valve replacement or repair, coronary artery bypass grafting) and has unstable angina, congestive heart failure, severe hypertension, or significant ventricular arrhythmias; or
• The member requires conversion from coumadin to intravenous heparin (not subcutaneous heparin) (see CPB 0200 - Coumadin (Warfarin) to Heparin Conversion Before and After Elective Surgery) for a surgical procedure planned for the next day (individuals with mitral valve disease, especially with atrial fibrillation, may require 2 pre-operative days); or
• The member requires intravenous steroid preparation for protection against a previously documented allergic reaction to dye prior to intravascular administration of dye necessary to perform a diagnostic study or operative procedure; or
• The member requires intravenous steroid preparation, intravenous anti-convulsant protection, or osmotic diuresis prior to a craniotomy scheduled for the following day (e.g., intracranial arterio-venous malformations).

Hospitalization Prior to Transplant:

Members awaiting transplants are commonly hospitalized prior to surgery.  Hospitalization of such individuals, however, is only considered medically necessary when the member has needs that justify inpatient confinement.  Assessment of the medical necessity of hospitalization prior to transplant surgery is performed using the same criteria that are considered in assessing the medical necessity of hospitalization for other conditions.