CurrentColorado Rocky Mountain Health PlansPolicy N/A

Medical Records Documentation Used for Reviews

Lists types of medical record documentation that may be required to support utilization review and coverage decisions across many service categories; intended for providers submitting requests to the payer's review process.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMedical Records Documentation Used for Reviews

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen submitting an authorization or coverage review, provide complete medical notes, recent diagnostic reports/images (submitted via the external portal), and documentation of prior treatments tried/failed with dates and reasons.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>40service categories listed in Table of Contents

>30distinct procedure/condition sections listing required documentation

~20+distinct device/service categories with specific documentation requirements

specificobjective measurements requested

12 months

pulmonologist re-evaluation timeframe (HMV)

6 monthsface-to-face encounter timeframe (DME)

Documentation and Coverage Criteria

inv-01: Documentation to support medical necessity (per service)

Documentation elements to support coverage review for each listed service category; include ALL applicable items when requesting review.

General documentation node: Diagnosis, history and physical, signs and symptoms (including impact on ADLs when applicable), comorbidities, treatments tried/failed/contraindicated with dates and reasons, and reports of all recent imaging and diagnostic testingvaries by service

Provider should include specific service-related items listed under each category (e.g., lab recency, device make/model, photos).

Photo requirement node: For certain procedures (e.g., breast reconstruction, breast reduction, eyelid repair, cosmetic procedures), submission of high-quality color photographs labeled with date and case number or member name/ID is required when Pre-Determination is requestedN/A

Photos must be submitted via the external portal; faxes not accepted for photos.

DME node: Provide current prescription/written order, HCPCS codes for item and each accessory, device make/model, rationale for device selection, prior device information for replacements, and face-to-face encounter documentation within six months when applicableN/A

Include physician plan of care and evidence of continued benefit for ongoing requests.

inv-02: Documentation-based coverage criteria (service-specific)

Coverage/authorization reviews require that ALL of the following service-specific documentation elements be supplied when applicable:

Facility admission (IRF/LTAC/SNF) initial admission: Hospital face sheet; history & physical; therapy evaluations; most recent therapy notes (within 24–48 hours); most recent physician note (within 24 hours); physician orders/medication list; post-procedure notes; nursing admission assessment.

Facility admission continuation of stay: Therapy evaluations within past 48 hours; most recent therapy notes within past 24–48 hours; most recent physician notes within past 24 hours; most recent nursing notes within past 24 hours where applicable.

Negative pressure wound therapy (NPWT): Diagnosis requiring NPWT; history; physical exam; signs/symptoms; prior treatments tried/failed/contraindicated with dates and reasons; wound stage/size/location/measurements; wound type; surgery dates including debridement; date NPWT started; evidence favorable wound environment; exclusions such as active bleeding, exposed vasculature, necrotic tissue, exposed bone/organs, malignancy in wound, open fistula, uncontrolled infection/osteomyelitis.

inv-03: Required documentation sets

Documentation requirements by procedure/condition — provider must supply the listed items when applicable for review

General imaging and report requirements: When requested, submit the specific diagnostic images that demonstrate the abnormality (MRI, CT, X-ray, bone scan) via the external portal; images must be labeled with date and case/member identifiers and accompanied by radiologist reports detailing relevant findings (e.g., instability, compression, herniation, quantification of subluxation/translation/angulation).

Prior treatments and clinical history: Provide prior therapies/treatments tried, failed, or contraindicated with dates, duration, and reasons; include symptoms, severity of pain, functional disability affecting ADLs, pertinent physical exam, comorbidities, and prior surgeries to same joint when applicable.

Procedure-specific items (examples): Provide additional items as applicable: joint-specific imaging details (Outerbridge/Tönnis grading for FAI), microbiology/synovial exams/ESR/CRP for joint infections, vein diameter and reflux measurements and validated venous disability scores for venous procedures, KPS/ECOG and life expectancy for stereotactic radiation, detailed neurologic findings for spine artificial disc requests, and vendor/device details for prosthetics.

Listing a service in these guidelines does not in itself indicate that the service is covered. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws, and whether a requested service is covered for a given member depends on the member's specific benefit plan and applicable regulatory requirements. Reviewers may also request additional information to determine whether the member meets clinical criteria for coverage.

For wound therapies such as Negative Pressure Wound Therapy (NPWT/Wound VAC), certain wound characteristics make the therapy inappropriate. Examples of conditions listed where NPWT should not be used in the vicinity of the wound include active bleeding or exposed vasculature, necrotic tissue, exposed bone/nerves/organs, malignancy in the wound, an open fistula to an organ or body cavity, and uncontrolled soft tissue infection or osteomyelitis. Documentation should address wound stage, size, type, debridement and dates, prior treatments and the current wound environment.

These document excerpts do not provide a list of explicit coverage exclusions beyond the wound-specific considerations noted elsewhere; the content focuses on the documentation required to assess medical necessity. Absence of an explicit exclusion in these sections does not imply coverage — benefit determination remains contract- and law-dependent.

When diagnostic images or clinical photographs are requested for review, they must be submitted through the payer's designated external portal. Faxes will not be accepted for images or photographs; failure to submit images via the portal may prevent completion of the review and risk denial. Images must also be appropriately labeled as directed (date and case/member identifiers).

No additional coverage criteria notes are provided in these excerpts.

Codes and Recency/Measurement Requirements

Examples of CPT codes called outCPT

19370	Breast reconstruction CPT code (as referenced)
19371	Breast reconstruction CPT code (as referenced)

Sleep study CPT examples mentionedCPT

CPT 95811	PAP titration or split night study (indicated in documentation guidance)
CPT 95805	Multiple Sleep Latency Testing (MSLT) / Maintenance of Wakefulness Testing (MWT)

Durable medical equipment codingHCPCS

HCPCS

Specific HCPCS code(s) for pneumatic compression device and accessories must be provided

FAI-related CPT codes referencedCPT

29914	Arthroscopy, hip, surgical; with labral repair
29915	Arthroscopy, hip, surgical; with femoroplasty
29916	Arthroscopy, hip, surgical; with acetabuloplasty

Recency windows for labs and assessments

Physical examwithin 3 months (example listed for office notes and diabetes CGM)

Basic metabolic/electrolyteswithin 6 months (example recency window)

Thyroid-stimulating hormone (TSH)within 12 months (example recency window)

Provider office notes and labs for diabetes/CGMwithin 3 months for initial requests; within 6 months for continued use (examples)

Tumor Treatment Field Therapy — wear time counseling

Minimum documented wear time counseling

What Providers Must Submit / Prior Authorization Steps

Note

Provider action note

Listing a service here does not guarantee coverage. Benefit coverage is determined by the member’s contract, state and federal law, and clinical criteria. Providers must submit complete documentation for prior authorization or pre-determination requests; failure to provide required materials may delay review or result in denial.

If requested images/photographs are not submitted via the external portal or are unlabeled, the request may be delayed or denied.
Do not fax color photographs or diagnostic images — submit via the external portal.

Prior Authorization

Prior authorization: breast reconstruction and photo requirement

For breast reconstruction and related cosmetic/reconstructive procedures when a Pre-Determination is requested, high-quality, color photographs are required. Photos must be labeled and submitted via the external portal; faxes are not accepted.

Purpose and Scope

Reviewers expect focused clinical and administrative documentation to determine medical necessity across a wide range of services. Core items include: the diagnosis and history of present illness; relevant physical examination findings (including functional impact and comorbidities); prior therapies tried, failed, or contraindicated with dates, duration and reasons for discontinuation; procedure- or device-specific details (e.g., device make/model and HCPCS codes, vendor invoice for prosthetics); and complete diagnostic testing and imaging reports. For many requests, submission of the actual labeled diagnostic images or high-quality color photographs via the external portal is required. Facility admission and continuation reviews commonly request recent therapy and physician notes (often within 24–48 hours for therapy notes and within 24 hours for the most recent physician note).

Terminology and Measurement Definitions

AHI, REI, RDI (sleep study severity metrics)

AHI/REI/RDI valuesReport sleep study severity metrics (Apnea–Hypopnea Index, Respiratory Event Index, Respiratory Disturbance Index) when documenting sleep apnea

Include study type and resultsProvide type of sleep study and numeric AHI/REI/RDI values to support treatment requests

Prior treatment documentationInclude prior treatments tried/failed/contraindicated (e.g., PAP intolerance) alongside severity indices

HCPCS — pneumatic compression devices and accessories

HCPCS codes for pneumatic compression devicesProvide specific HCPCS code(s) for the device and each accessory requested

Equipment make/model and price quote

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMedical Records Documentation Used for Reviews

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Obstructive/central sleep apnea treatments (oral appliance or surgical): Diagnosis; current evaluation by physician/APP; current written order; signs/symptoms; comorbidities; sleep study results (AHI/REI/RDI); prior treatments tried/failed/contraindicated including PAP intolerance or lack of efficacy; additional procedure-specific elements for surgeries and device implants (e.g., BMI, obstruction type, imaging).

Procedures requiring imaging/photos (e.g., orthognathic, rhinoplasty, panniculectomy): High-quality, labeled diagnostic images and/or color photographs; imaging reports; cephalometric tracings where applicable; images labeled with date and case number or member name/ID; submitted via external portal.

Device/equipment requests (e.g., pneumatic compression devices): Current prescription/order including initial/ongoing/replacement, rental vs purchase, specific HCPCS codes, equipment make/model/price quote, justification for device features, status of existing device and warranty if replacement.

Surgical/procedural requests (example: prostate surgeries, spine, sinus, SI joint): Procedure requested; diagnosis and staging where relevant; history and comorbidities; signs/symptoms; prior treatments tried/failed/contraindicated with dates/reasons; relevant diagnostics and imaging reports; physician treatment/surgical plan and privileging info if site of service question.

Revision surgery requirements: For revision surgeries include documentation of complications, details of prior procedures, and a complete (staged) surgical plan.

Member counselled to wear device at least 18 hours per day

Documentation required (glioblastoma treatment)Physician notes must document counseling and concurrent temozolomide use where applicable

Recurrent disease counselingFor recurrent glioblastoma also document counseling that device be worn ≥18 hours/day

Pulmonologist re-evaluation interval for ongoing HMV

Pulmonologist or treating physician re-evaluationRe-evaluation documented within 12 months for ongoing home mechanical ventilator (HMV) requests

Include evidence of proper use and continued benefitDocumentation should show proper use and continued benefit for ongoing requests

Supportive diagnostic testingInclude ABGs, PFTs, overnight oximetry or sleep study results when available

Face-to-face encounter timeframe

Face-to-face encounter timeframeDocumented face-to-face encounter within six months prior to the prescription (written order), when applicable

Include date of encounterProvider must include date of the face-to-face encounter in office notes when requested

Applies to DME and devicesFace-to-face documentation is requested for DME items such as speech devices, lifts, wheelchairs when applicable

BMI documentation

Body Mass Index (BMI)Document BMI when requested (e.g., for hypoglossal nerve stimulation, maxillomandibular advancement eligibility)

Include weight and heightProvide most recent member weight and height when device/procedure eligibility depends on BMI

Contextual useBMI requested as part of obstructive/central sleep apnea surgical evaluations and device implant criteria

Bladder capacity

Bladder capacityProvide bladder capacity in milliliters when requested for sacral nerve stimulation evaluations

Operational abilityDocument individual's capacity to operate the device when requesting sacral nerve stimulation

Permanent implant documentationFor permanent implantation include percentage improvement after screening trial where applicable

Applicable CPT(s) must be listed on the request.
Photos for CPT 19370 and 19371 require high-quality color photographs.
All photographs must be labeled with: date taken and either the applicable case number obtained at time of notification or the member’s name and ID number.
Submission method: external portal (www.uhcprovider.com/paan). Faxes of color photos will not be accepted.

Documentation Required

Prior authorization documentation

For all prior authorization requests, include complete documentation to support medical necessity. Incomplete or missing documentation increases the risk of denial or delay.

Diagnosis and relevant history including onset, duration, frequency, and impact on ADLs.
Current physician plan of care and specific procedure or device requested (include CPT/HCPCS codes).
For device/DME requests include make, model, settings, hours of use, and rationale for selection.
Face-to-face encounter documentation when required (see specific DME sections).
Provide dates, duration and reasons for discontinuation for prior therapies, trials, or conservative treatments.
When deviation from standard accessories or configurations is requested, include justification and vendor quote.

Documentation Required

Imaging required for review

Diagnostic imaging must be submitted when requested for review. Images and reports must be clearly labeled and uploaded via the external portal; faxes will not be accepted.

When requested, include the specific diagnostic image(s) that show the abnormality (MRI, CT, X‑ray, bone scan, etc.).
Images must be labeled with the date taken and either the applicable case number obtained at time of notification or the member’s name and ID number.
Submit images via the external portal (www.uhcprovider.com/paan); faxes will not be accepted.
If imaging is requested, include the radiology report(s) describing presence/absence of findings relevant to the request (e.g., cord compression, instability, lesion size/location).

Prior Authorization

HMV ongoing request re-evaluation

For ongoing Home Mechanical Ventilator (HMV) requests, include re-evaluation documentation from the pulmonologist or treating physician within the prior 12 months and evidence of ongoing benefit and proper use.

Include current prescription/order indicating initial vs ongoing request, primary/secondary/backup use, device make/model, device settings, and hours of use per day.
Provide recent relevant testing (ABGs, PFTs, overnight oximetry, sleep study) as available.
For continuation requests, include documentation of patient tolerance, proper use, compliance, and a pulmonologist/treating physician re-evaluation within 12 months.

Documentation Required

Photograph submission requirements

Photograph submission requirements apply beyond breast reconstruction (e.g., breast reduction, panniculectomy, eyelid/brow repairs, flap repairs). Photos must be high-quality, labeled, and uploaded through the portal.

Label photos with date taken and applicable case number or member name/ID.
Specify required views when listed (e.g., full face frontal and lateral for eyelid/brow; full-frontal and lateral views for panniculectomy).
Submission method: external portal (www.uhcprovider.com/paan). Faxes will not be accepted.

Prior Authorization

DME documentation specifics

DME, orthotics, prosthetics and related device requests require specific device details, prescription information, and justification for the chosen equipment or any non‑standard accessories.

Include current prescription (written order) indicating initial/replacement, rental vs purchase, HCPCS code(s) for item and each accessory requested.
Provide equipment make, model, price quote, and vendor coversheet/invoice listing HCPCS codes and descriptions.
Document rationale for selection of a specific device and accessories and reasons for deviation from standard accessories.
For repairs/replacement include date of original acquisition, warranty status, history of repairs, serial number, and replacement/repair quote; if stolen include police report.
For mobility devices include ambulation/transfer status, functional limitations related to ADLs/MRADLs, and measurements/strength testing as applicable.

Documentation Required

Prosthetics documentation

Prosthetics requests require vendor and clinical documentation demonstrating the need and details to fit and fabricate the device.

Vendor coversheet with narrative describing the request and vendor invoice listing HCPCS codes, make/model, and laterality (right/left).
Current prescription and final prosthetic proposal from ordering physician.
Physician notes documenting residual limb examination (length/shape/skin integrity), functional classification level, comorbidities, date and level of amputation, and expected rehabilitation potential.
For socket or replacement requests include age of current socket/prosthesis, reason for replacement, comparative residual limb measurements, and adjustments attempted.

Documentation Required

Radiation therapy documentation

Radiation therapy (IMRT, SBRT/SRS, stereotactic therapies) authorization requests require detailed planning documentation, dose prescriptions, and supporting clinical information.

For IMRT: submit dose prescription and clearly labeled, color comparative 3D and IMRT plans including dose-volume histograms (DVH) and dose table in absolute doses.
When citing an RTOG dose constraint include the RTOG protocol number.
For SBRT/SRS and TARE/SIRT include diagnosis, patient performance status (KPS/ECOG), life expectancy, treatment plan (number of fractions), number/size/location of tumors, and relevant imaging reports.
If treating adjacent previously irradiated areas, provide documentation describing prior radiation and need for abutting portals with high precision.

Prior Authorization

naviHealth IRF/LTAC initial and continuation documentation

naviHealth reviews for IRF, LTAC, and SNF admissions and continuations require specific acute care and recent therapy/physician documentation to support level-of-care and ongoing need.

Initial admission: hospital face sheet, H&P, therapy evaluations, most recent therapy notes within 24–48 hours, most recent physician note within 24 hours, physician orders/med list, post-procedure notes, and nursing admission assessment.
Continuation of stay: therapy evaluations within past 48 hours, most recent therapy notes within 24–48 hours, and most recent physician notes within 24 hours (and most recent nursing notes for LTAC/SNF as applicable).
Omission of recent therapy or physician notes (often requested within 24–48 hours) may trigger denial or delay.

Prior Authorization

naviHealth SNF initial and continuation documentation

naviHealth requirements for Skilled Nursing Facility (SNF) initial admissions and continuations mirror IRF/LTAC expectations — submit acute care documentation and very recent therapy/physician/nursing notes to support the request.

Initial admission: hospital face sheet, H&P, therapy evaluations, most recent therapy notes (within 24–48 hours), most recent physician note (within 24 hours), physician orders/med list, post-procedure notes, nursing admission assessment.
Continuation: therapy evaluations within past 48 hours; most recent therapy and physician notes within 24–48 and 24 hours respectively; most recent nursing notes within past 24 hours.
Failure to provide these recent notes may result in denial or request for additional information.

Documentation Required

Diagnostic image labeling and submission

Diagnostic images and radiology reports submitted for review must be clearly labeled and include the relevant interpretive information required for decision-making.

Label images with date taken and applicable case number or member name/ID.
Provide radiologist reports that address the specific findings requested (e.g., presence/absence of spinal instability, cord compression, disc herniation, tumor size/location, degree of reflux or vein diameter).
Include full reports of diagnostic tests (biopsy, bone aspirate, microbiology, synovial exams) when requested.
Submit images and reports via the external portal; faxes will not be accepted.

Documentation Required

Required imaging reports

When imaging is requested, include complete radiology reports that explicitly state the relevant findings referenced by the clinical criteria; absence of a complete report may delay review.

Reports should quantify or describe the requested elements (e.g., measurements, grades, presence/absence of metastasis, tumor size/location, degree of reflux, Outerbridge grade, etc.).
Include specialty(ies) of the interpreting provider when applicable and any comparative imaging if used to show progression.
If imaging images are requested in addition to reports, ensure the images are the ones that demonstrate the abnormality and are properly labeled.

Documentation Required

Clinical history and treatment attempts

Provide a thorough clinical history and documentation of treatment attempts and outcomes. Reviewers expect objective measures and dates to support medical necessity.

Document diagnosis, history of present illness, relevant physical exam findings, comorbidities, and impact on ADLs.
List prior therapies/treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation (including medications, injections, conservative care, bracing, physical therapy, etc.).
When a trial period is required before a procedure/device, provide objective measures of response and duration (e.g., pain scores, functional scales, validated disability scores such as VCSS or VDS).
Include documentation of complications or prior surgical failures when applicable and relevant lab/test results supporting the clinical picture.

Step Therapy

Treatment trial documentation / Prior therapies requirement

Many procedures and device requests require documentation of prior conservative therapy trials with specifics on dates, duration, and reason for discontinuation or failure.

Provide start and stop dates for conservative treatments and the objective or subjective outcome that defines failure.
For venous procedures, vertebral tethering, NPWT, ventilators, wound care, and similar services, document prior conservative measures and why they were insufficient.
Include reasons therapy was not appropriate or contraindicated when applicable.

Documentation Required

For procedures like NPWT and panniculectomy: prior treatments and documentation

For services such as Negative Pressure Wound Therapy (NPWT), panniculectomy, and other procedures where prior treatments affect necessity, include detailed prior treatment history and wound/surgical details.

NPWT: document wound type, stage, size, measurements, date(s) of surgery/debridement, prior NPWT use on the same wound and outcomes, and that wound is free of uncontrolled infection, exposed vasculature, or malignancy.
Panniculectomy: provide history of weight loss, BMI, duration of weight stability, dermatologic complications and treatments tried, and when requested, high‑quality labeled photos.
When prior attempts at nonoperative care exist, include dates, duration, and objective evidence of inadequate response.

Include equipment make, model and price quotation alongside HCPCS codes

Replacement detailsIf replacement, list current device, date of acquisition, warranty status and reason for replacement

Performance status scores (KPS / ECOG)

Karnofsky (KPS) or ECOG performance statusProvide KPS or ECOG results when requested to document functional capacity for device or oncology-related requests

Use in device/therapy requestsPerformance status requested for electric tumor treatment field therapy, bone growth stimulators, stereotactic radiation and similar services

Include life expectancy or prognosis when applicableProvide life expectancy or related prognostic information if requested alongside performance status scores

Outerbridge / Tönnis grading (cartilage grading for FAI)

Outerbridge or Tönnis gradeReport Outerbridge or Tönnis grading for cartilage damage when requested for femoroacetabular impingement (FAI) and hip surgery evaluations

Include defect size/locationProvide size and location of focal cartilage defect and joint space/alignment details when applicable

Submit supporting images and reportsUpon request submit diagnostic images labeled with date and case/member identifiers and accompanying imaging reports