Clinical UM Guideline

This document addresses the appropriate use of preoperative testing for certain elective, low risk invasive procedures and non-cardiac surgeries. The specific tests included in this document are complete blood count (CBC), white blood cell count (WBC), prothrombin time (PT)/ partial thromboplastin time (PTT), metabolic panel, urinalysis, chest x-rays, resting electrocardiogram (ECG), resting echocardiogram and pre-procedure consultations.

Medically Necessary:

Preoperative testing is considered medically necessary when ALL the following criteria are met (A, B, and C):

1. Preoperative testing may include any, or all, of the following when done as part of a preoperative evaluation before low risk invasive procedures or non-cardiac surgeries:
   1. Comprehensive blood counts (CBC, WBC, PT/PTT, metabolic panel);
   2. Urinalysis;
   3. Chest X-rays;
   4. Resting ECG;
   5. Resting echocardiogram;
   6. Pre-procedure consultations.
      and
2. Low risk invasive procedures and surgeries may include the following when criteria are met:
   1. Cataract surgery;
   2. Glaucoma surgery;
   3. Upper endoscopy;
   4. Colonoscopy;
   5. Cystoscopy;
   6. Arthroscopy.
      and
3. Preoperative testing is considered medically necessary for persons 65 years of age or older or for persons less than 65 years of age with risk factors for postoperative complications or symptoms suggestive of a significant systemic disease process (ASA III or IV*) when the same tests have not been performed in the previous 30 days and when ANY of the following conditions are present:
   1. Anemia; or
   2. Bleeding disorders; or
   3. Other hematologic disorders; or
   4. Cardiovascular disease; or
   5. Pulmonary disease; or
   6. Renal disease; or
   7. Liver disease; or
   8. Endocrine disease; or
   9. Malignancy; or
   10. Hypertension; or
   11. Diabetes; or
   12. Recent upper respiratory infection; or
   13. History of smoking; or
   14. History of alcohol abuse; or
   15. History of steroid use; or
   16. History of anticoagulant therapy.

Note: *For definitions of American Society of Anesthesiologists (ASA) physical status classifications, see the Definitions section.

Not Medically Necessary:

Preoperative testing is considered not medically necessary when ALL of the following criteria are met:

• Age between 16 and 65 years of age; and
• When the same tests have been performed within 30 days prior to the planned procedure; and
• Asymptomatic persons without significant systemic disease (ASA I or II*) of any system or risk factors for postoperative complications.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:
For the following procedures performed preoperatively for the surgical procedures described in the Clinical Indications section:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, or for situations designated in the Clinical Indications section as not medically necessary.

Multiple medical specialty societies have published recommendations on the need for performing routine tests (for example, blood counts, chest x-ray and ECG), as part of the preoperative work-up before invasive procedures and surgeries considered low risk for postoperative complications in healthy individuals less than 65 years of age.

The following are excerpts from the American Society of Anesthesiologists (ASA) on considerations regarding preoperative testing:

Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease. Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained…The risk specifically related to the surgical procedure could, however, modify the preoperative recommendation to obtain laboratory studies and, when the need arises, the decision to implement should include a joint decision between the anesthesiologists and surgeons. This should be applicable to all outpatient surgery...The role of preoperative cardiac stress testing has been reduced to the identification of extremely high-risk individuals, for instance, those with significant left main disease for which preoperative revascularization would be beneficial regardless of the impending procedure. In other words, testing may be appropriate if the results would change management prior to surgery, could change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform (Apfelbaum, ASA, 2012).

Regarding the performance of 12-lead resting ECG, the American College of Cardiology, American Heart Association (ACC/AHA) guideline on Perioperative Cardiovascular Evaluation and Management of Patients undergoing Non-cardiac Surgery (2014) provided the following guidance:

Preoperative resting 12-lead electrocardiogram (ECG) is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery (Class IIa; Level of Evidence: B).

Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery (Class IIb; Level of Evidence: B).

Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures (Class III Harm; Evidence level: B). (Fleisher, 2014)

A number of retrospective studies with large sample sizes (minimum of 15,000) used data from the National Surgical Quality Improvement Program (NSQIP) database to evaluate the association between preoperative testing and surgical outcomes. Studies addressed a variety of clinical areas. Study findings were mixed, with many studies finding that the findings of at least some tests predicted postoperative outcomes.

In 2022, Taylor and colleagues published an analysis of outcomes after preoperative testing in 111,589 individuals in the NSQIP database who underwent low-risk ambulatory surgery. About half of individuals (n=57,590, 51.8%) had preoperative laboratory testing. Individuals who were undergoing gynecologic, urologic, endocrine or vascular surgery were more likely than the overall cohort to have had preoperative testing. The most common tests were at least one component of a CBC (40.7% of participants), basic metabolic panel (BMP) (41.9%), liver function test (LFT) (20.5%) and a coagulation study (10.7%). There was not a statistically significant difference in the mortality rate between individuals with preoperative testing (0.02%) versus those without preoperative testing (0.01%), p=0.12. The rate of serious morbidity was 1.2% among tested individuals and 1.1% among non-tested individuals. The difference between groups was statistically significant (p=0.01), but this is likely due to the large sample size and the difference does not appear to be clinically significant. There were no statistically significant differences between groups in the specific complications of unplanned reoperation, infection, deep surgical site infection, deep vein thrombosis, pulmonary embolism, cardiac arrest and septic shock. Among individuals who had preoperative testing, there were small (less than 1% difference) but statistically significantly higher rates of several complications including superficial surgical site infection, unplanned reintubation, renal insufficiency, urinary tract infection, unplanned reoperation and sepsis. Individuals who underwent preoperative testing tended to be at higher risk e.g., were older and had more comorbidities.

Several analyses addressed gynecological surgery. Muller and colleagues (2021) included 19,855 individuals from the NSQIP database who had gynecological surgery. Of these, 14,258 (71.8%) had at least one preoperative laboratory test, the most common of which were CBC (70.4%) and chemistry panels (33.5%). The analysis did not find a statistically significant difference in the overall complication rate in the group that did receive preoperative testing (2.5%) versus those who did not receive preoperative testing (2.2%, p=0.30). More specifically, there were not significant differences in the rate of major complications (1.0% versus 0.8%, respectively, p=0.11), wound complications (1.0% versus 1.0%, p=0.78) or the unplanned readmission rate (0.7% versus 0.5%, p=0.10). Sears (2020) utilized data on 24,752 hysterectomies in the NSQIP database to study the utility of preoperative testing. Most of the individuals (92.5%) had laboratory testing prior to surgery, most commonly CBC (92.5%), renal function panel (RFP) (84.5%), LFT (70.5%) and coagulation studies (63.2%). A total of 7680 of 22,905 (33.5%) individuals who underwent preoperative testing had at least one abnormal result. A low hematocrit was the most common abnormality, occurring in 14% of individuals who underwent CBC testing. Individuals with normal preoperative testing values had a significantly lower rate of complications (6.2%) than those with abnormal findings (10.6%) and those who did not get tested (10.3%); the difference among groups was p<0.001. The most common surgical complication was blood transfusion, which occurred less frequently in individuals with normal laboratory test results (1.6%) compared with those with abnormal results (5.8%) or no preoperative testing (5.1%), p<0.001. In a multivariate logical regression model adjusting for a variety of clinical and demographic factors, WBC count and low hematocrit were significantly associated with an increased rate of complications. In the multivariate model, other tests such as the RFP and LFT were not significantly associated with the complication rate.

There are also studies focusing on laboratory testing prior to orthopedic surgery. Ondeck and colleagues (2019) examined data from NSQIP on 92,093 individuals who underwent primary total hip arthroplasty (THA). The authors evaluated the association between preoperative sodium, blood urea nitrogen (BUN) and creatinine levels and adverse events after surgery. A total of 13,736 (14.9%) individuals experienced an adverse event and 2025 (3.2%) experienced a serious adverse event. In multivariate logistic regression models, low preoperative sodium was significantly (p<0.001) associated with all adverse events (minor or major adverse event, extended hospital stay, discharge to a higher level of care and readmission). Elevated preoperative sodium was not associated with any type of adverse event. Low preoperative BUN was significantly associated with an extended hospital stay (p<0.001) and discharge to a higher level of care (p<0.006). Elevated preoperative BUN was significantly associated with all adverse outcomes except hospital readmission (p<0.005). For the third laboratory test, preoperative creatinine, in multivariate models low values were significantly associated with any adverse event, minor adverse events, extended hospital stay and discharge to a higher level of care (p<0.001). Elevated preoperative creatinine was associated with all postoperative adverse events (p<0.001).

An NSQIP analysis by Zreik and colleagues (2020) studied the association between preoperative laboratory testing and adverse outcomes in 47,111 individuals who underwent anterior cervical discectomy and fusion (ACDF). A number of laboratory values were examined including blood urea, nitrogen, creatinine, hematocrit, platelet count, sodium and white blood cell count. Outcomes of interest were any 30-day complication, serious 30-day complications, 30-day unplanned readmissions and discharge to a non-home facility. A total of 22,019 (46.7%) of individuals had at least one abnormal preoperative laboratory test. At least several abnormal (high or low) laboratory tests were associated with each of the above outcomes. For example, high creatinine, low hematocrit, low sodium and high white blood cell count were associated with any 30-day complication.

Taylor (2021) published an analysis of 35,745 individuals from the NSQIP database who underwent elective endocrine surgery. A total of 20,972 (58.7%) underwent preoperative laboratory testing, defined as receipt of a blood test captured by the database within 30 days of surgery, excluding components of a chemistry panel. At least one component of a CBC was obtained for 20,029 (56.0%) individuals, at least one component of an LFP was obtained by 10,193 (28.5%) of individuals and at least one coagulation study was done in 6096 (17.1%) individuals. Abnormal tests were found in 25.9% of CBCs, 25.2% of LFPs and 21.8% of coagulation studies. The overall complication rate, 1.8%, differed significantly between individuals who received preoperative tests and those who did not (1.9% versus 1.7%, p=0.12). Moreover, rates of wound complications (0.3% versus 0.2%, p=0.33), procedure-related complications (0.3% versus 0.2%, p=0.32), major complications (0.4% versus 0.4%, p=0.25) or mortality (0.0% versus <0.1%, p=0.17) also did not differ by preoperative testing status. In a multivariate analysis of factors associated with poor outcomes, hypertension requiring medication, but not preoperative testing was significantly associated with morbidity or unplanned hospital readmission.

Benarroch-Gampel (2012) analyzed data on 73,596 individuals identified from the NSQIP database who underwent elective hernia repair. Preoperative laboratory testing was defined as any laboratory test obtained within 30 days of surgery. Laboratory tests collected in the NSQIP included hematocrit, white blood cell count, platelet count, sodium, BUN, creatinine, PTT, PT, International Normalized Ratio (INR), albumin, total bilirubin, aspartate aminotransferase, and alkaline phosphatase. A total of 46,977 (63.8%) subjects underwent testing, with at least one abnormal test recorded in 61.6% of trial participants. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of the included subjects. After adjusting for individual and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications.

A smaller retrospective study focused on the pediatric population. The study aimed to determine the utility of routine preoperative coagulation tests (PT and activated partial prothrombin time [APTT]) (Alzahrani, 2019). The study included 2078 healthy children under 15 years old who were admitted to the hospital for elective mild to intermediate surgery or for invasive procedures. A total of 1940 out of 2078 cases (93.4%) had normal coagulation tests, 77 cases (3.7%) had abnormal test results and 61 individuals (2.9%) did not undergo preoperative testing. Postoperative bleeding occurred in 3 individuals (0.1%), 3 of which had normal findings on preoperative testing and 1 of which had not undergone preoperative testing. The authors concluded that routine preoperative coagulation screening in healthy individuals is not recommended.

Physical Status Classification System: This was established by the American Society of Anesthesiologists (ASA) to provide a basic scale for use in determining an individual’s fitness to undergo anesthesia as follows:

ASA grade I: A normal healthy person;
ASA grade II: A person with mild systemic disease;
ASA grade III: A person with severe systemic disease;
ASA grade IV: A person with severe systemic disease that is a constant threat to life

Risk Factors for Coronary Artery Disease (CAD): Long-standing risk factors for the development of CAD have typically included age, blood levels of total and high-density lipoprotein (HDL) cholesterol, blood pressure, cigarette use, diabetes mellitus, and left ventricular hypertrophy on ECG.

Surgical Grades: A classification system adopted by the Guideline Development Group of the National Institute for Health and Care Excellence (NICE, updated 2016) with examples as follows:

Minor surgery: 

• Removal of skin lesions;
• Draining an abscess;

Intermediate surgery: 

• Primary repair of inguinal hernia;
• Excision of varicosities of lower extremities;
• Knee arthroscopy;
• Tonsillectomy or adenotonsillectomy;

Major or Complex surgery:

• Total abdominal hysterectomy;
• Endoscopic resection of prostate;
• Lumbar discectomy;
• Thyroidectomy;
• Total joint replacement;
• Lung operations;
• Colonic resection;
• Radical neck dissection.

Peer Reviewed Publications:

1. Alzahrani A, Othman N, Bin-Ali T, et al. Routine preoperative coagulation tests in children undergoing elective surgery or invasive procedures: Are they still necessary? Clin Med Insights Blood Disord; 2019: 12:1-4.
2. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012; 256(3):518-528.
3. Mutter O, Taylor GA, Grebenyuk E et al. Utility of routine preoperative laboratory testing for low-risk patients in ambulatory gynecologic surgery. J Minim Invasive Gynecol. 2021; 28(5):1033-1040.
4. Ondeck NT, Fu MC, McLynn RP et al. Preoperative laboratory testing for total hip arthroplasty: unnecessary tests or a helpful prognosticator. J Orthop Sci. 2019; S0949-2658(19): 30314-8.
5. Rodríguez-Borja E, Corchon-Peyrallo A, Aguilar-Aguilar G, Carratala-Calvo A. Utility of routine laboratory preoperative tests based on previous results: time to give up. Biochem Med (Zagreb). 2017; 27(3):030902.
6. Sears S, Mangel J, Adedayo P, et al. Utility of preoperative laboratory evaluation in low-risk patients undergoing hysterectomy for benign indications. Eur J Obstet Gynecol Reprod Biol. 2020; 248:144-149.
7. Soares Dde S, Brandao RR, Mourao MR, et al. Relevance of routine testing in low risk patients undergoing minor and medium surgical procedures. Rev Bras Anestesiol. 2013; 63(2):197-201.
8. Taylor GA, Liu JC, Schmalbach CE et al. Preoperative laboratory testing among low-risk patients prior to elective ambulatory endocrine surgeries: A review of the 2015-2018 NSQIP cohorts. Am J Surg. 2021; 222(3):554-561.
9. Taylor GA, Oresanya LB, Kling SM et al. Rethinking the routine: Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program cohort. Surgery. 2022; 171(2):267-274.
10. Zreik J, Goyal A, Alvi MA, et al. Utility of preoperative laboratory testing in assessing risk of adverse outcomes after anterior cervical discectomy and fusion: insights from national surgical registry. World Neurosurg. 2020; 136:e398-e406.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Agency for Healthcare Research and Quality (AHRQ). Balk EM, Earley A, Hadar N, et al. Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness. Comparative Effectiveness Review. No. 130. (Prepared by Brown Evidence-based Practice Center under Contract No. 290-2012-0012-I.). AHRQ Publication No. 14-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2014.
2. Apfelbaum JL, Connis RT, Nickinovich DG, et al.; American Society of Anesthesiologists (ASA) Task Force on Preanesthesia Evaluation on Standards and Practice Parameters. Practice advisory for preanesthesia evaluation: an updated report by the ASA Task Force on Preanesthesia Evaluation. Anesthesiology. 2012; 116(3):522-538.
3. Douglas PS, Garcia MJ, Haines DE. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2011; 24:229-267.
4. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 2007; 50:e159-242.
5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130(24):2215-2245.
6. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010; 56:e50-103.
7. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol. 2009; 53:2201-2229.
8. Keay L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012; (3):CD007293.

1. MedlinePlus Medical Encyclopedia. Tests and visits before surgery. Updated February 28, 2022. Available at: https://medlineplus.gov/ency/patientinstructions/000479.htm. Accessed on June 5, 2024.

CBC, Complete blood count
CXR, Chest x-ray
Echocardiogram, Resting
EKG, ECG, Electrocardiogram, Resting
Metabolite panel
Preoperative consultation
Preoperative testing
PT/PTT, Prothrombin, Partial Thromboplastin Time
U/A, Urinalysis
WBC, White blood cell count

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.