CGM and Insulin Delivery — Prior Authorization Documentation

When requesting prior authorization for continuous glucose monitors (CGM) or insulin delivery devices, include documentation specific to the device and clinical need. For initial and ongoing CGM/insulin delivery requests supply: member diabetes type (e.g., type 1, type 2, gestational); recent lab results and office notes (within 3 months for initial requests; within 6 months for continuation requests as noted below); a current signed physician order; the treatment plan; and the device make and model. For CGM initial requests include frequency and severity of hypoglycemic events (with glucose values) and for continued use include physician assessment documenting adherence and benefit. For insulin delivery devices include current signed physician order, treatment plan, device make/model, and recent relevant labs and notes (within 3 months).

• Provide device make/model and current signed physician order
• Include treatment plan and recent labs/office notes (3 months initial; 6 months for some continuation reviews)
• Document hypoglycemia frequency/severity for CGM initial requests and adherence/benefit for continued use

Imaging Submission Requirement and Method

When diagnostic images are requested as part of the review, submit the labeled image files via the external portal at www.uhcprovider.com/paan. Do not fax images or color photographs — faxes will not be accepted. Label each image with the date taken and the applicable case number obtained at time of notification, or the member's name and ID number. If radiology reports are requested, include the interpreting provider specialty and complete report.

• Images must be labeled with date and case number or member name/ID
• Submit images and photos only via the external portal: www.uhcprovider.com/paan (faxes not accepted)
• Include radiology reports and interpreter specialty when requested

Required Documentation (per Service Category)

Provide the specific clinical documentation listed for the requested service category. At minimum, include diagnosis, history of present illness, relevant physical exam findings, recent diagnostic testing and imaging reports, and a clear physician treatment plan. For procedures and devices, include the specific CPT/HCPCS code(s), device make/model, and current prescription or order when applicable. Be sure to document therapies and treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation.

• Diagnosis, HPI, pertinent physical and neurologic exams
• Recent imaging and diagnostic reports with dates and interpreter when applicable
• Physician treatment plan and applicable CPT/HCPCS codes
• Therapies/treatments tried, failed, or contraindicated with dates and reasons

HMV vs PAP/RAD — Required Documentation

For requests that may require a home mechanical ventilator (HMV) versus positive airway pressure (PAP) or respiratory assist devices (RAD), submit comprehensive respiratory documentation. Include medical history and respiratory condition supporting need for HMV rather than PAP/RAD; relevant objective testing (ABGs, pulmonary function tests if available, overnight oximetry, sleep study results when available); physician plan of care describing use pattern (intermittent, nocturnal, or continuous), device settings/hours of use, and member compliance. For ongoing HMV requests include recent pulmonologist re-evaluation (within 12 months) and documentation of proper use and continued benefit.

• ABGs, PFTs, overnight oximetry, and sleep study results when available
• Physician plan of care with intended hours of use and device settings (include make/model)
• Re-evaluation by treating pulmonologist within 12 months for ongoing requests; documentation of benefit and proper use

IMRT — Documentation Requirements

For advanced radiation planning requests such as IMRT, provide detailed oncologic documentation: diagnosis and target volumes, prior radiation history including dates and doses, rationale for IMRT versus conventional therapy, proposed dose and fractionation, and any required tumor or performance status data. For specific anatomical sites, include site‑specific questions (for example, internal mammary node treatment for breast IMRT or presence/absence of brain metastasis for whole brain IMRT) and performance status (ECOG or KPS) and prognosis if requested.

• Diagnosis, target volume/field and prior radiation doses and dates
• Rationale for IMRT instead of conventional therapy and proposed dose/fractionation
• ECOG or KPS performance status and site‑specific details (e.g., internal mammary node treatment)

Admission and Continuation of Stay Documentation (naviHealth)

For admissions and continuation of stay reviews for IRF, LTAC, and SNF (naviHealth-managed), include complete hospital and clinical documentation. For initial admission provide hospital face sheet, history & physical, therapy evaluations, most recent therapy notes (within prior 24–48 hours), most recent physician note (within 24 hours), physician orders/medication list, post-procedure notes, and nursing admission assessment. For continuation of stay submit recent therapy evaluations (within 48 hours), most recent therapy notes (within 24–48 hours), and most recent physician and nursing notes (within 24 hours) as applicable.

• Initial admission: hospital face sheet, H&P, therapy evaluations, recent physician and therapy notes, physician orders/med list, nursing admission assessment
• Continuation of stay: therapy evaluations within 48 hours, therapy notes within 24–48 hours, recent physician and nursing notes within 24 hours

Treatments Tried/Failed — Documentation Expectation

Many services require documentation of prior treatments tried and failed (or contraindicated). Always document specific therapies or interventions with start and stop dates, duration, and explicit reasons for discontinuation or failure. Include objective response measures when applicable (e.g., pain scores, imaging results, AHI for sleep apnea). For device or procedure requests show conservative management attempts and why they were inadequate before approval will be considered.

• List treatments tried with dates, duration, and reason for discontinuation
• Provide objective measures of response when applicable (e.g., pain scale, imaging, sleep indices)
• For device/procedure requests, document conservative management attempts and documented failure or contraindication

Therapies Tried/Failed — Required Details

Clinical documentation must explicitly show therapies and/or treatments that were tried, failed, or are contraindicated, including dates, duration, and reason for discontinuation. This is required across many categories (medical, surgical, device requests, DME) and supports medical necessity determinations. Failure to provide these details may delay review or lead to denial.

• Therapies/treatments with start/stop dates and reasons for discontinuation
• Documentation of contraindications when applicable
• Rehabilitation, medication, or device trials and documented clinical response

Site‑of‑Care Documentation — Inpatient vs Outpatient

When site‑of‑care is relevant (inpatient vs outpatient) include documentation that supports inpatient status: bilateral procedures, significant comorbidities that increase perioperative risk, inability to safely receive postoperative care as outpatient, or other clinical indicators such as need for monitoring or postoperative interventions. Provide the surgical plan, ASA score when applicable, physician privileging information if the outpatient location is not an office, and any barriers to outpatient care.

• Documentation supporting inpatient care: bilateral procedure, significant comorbidities, or lack of home supports
• Surgical plan and ASA score when applicable
• Physician privileging information and specific reasons why outpatient care is unsuitable