CurrentUnitedHealthcarePolicy N/A

Medical Records Documentation Used for Reviews: Community Plan

Lists the medical record documentation that may be required to support coverage reviews for many service categories across UnitedHealthcare Community Plans; affects providers submitting requests for coverage and prior authorization documentation for members in applicable Community Plans.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Records Documentation Used for Reviews: Community Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit complete, legible medical records and labeled diagnostic images/photos via the external portal to support prior authorization reviews.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+service categories listed

Portal requiredportal required

Image submission requiredimages required for some requests

Community Plansapplicability

Coverage criteria and general requirements

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Documentation and medical necessity criteria (general)

Medical necessity reviews require ALL applicable documentation items below to be present as applicable to the specific service requested.

General required documentation: Relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that support medical necessity must be in the patient's record and made available upon request.

Includes clear high-quality imaging and labeled photographs when applicable.

Imaging and labeling: When diagnostic images or photographs are requested, they must be labeled with date taken and case number or member name and ID, and submitted via the external portal (faxes not accepted).

Specific image types and views are specified per procedure (e.g., cephalometric tracings for orthognathic surgery; color comparative DVH for proton therapy).

Procedure-specific items: Additional required documentation varies by procedure and may include: detailed history and symptoms; prior treatments tried, failed, or contraindicated with dates and reasons; specialist evaluations; operative reports; device name/model and HCPCS codes; validated functional scores or PROMs; and a physician treatment plan addressing how the requested service will improve or restore function.

Providers should follow the section for the specific service being requested.

Documentation-based medical necessity criteria (by procedure)

Covered when medical record includes the following supporting documentation as applicable to the requested procedure:

General documentation: Relevant medical history; pertinent physical examination; results of pertinent diagnostic tests or procedures; and legible records made available upon request.

Applies across sections.

Imaging: Complete diagnostic interpretation of imaging (relevant clinical info, detailed findings, impression) and, when requested, diagnostic images labeled with date and case number or member name/ID submitted via the external portal.

Specific imaging elements vary by procedure (e.g., joint cartilage grading for hip FAI; CT/MRI levels for spine).

Symptoms and function: Documentation of symptoms, onset, duration, severity, and functional disability with impact on activities of daily living using standard scales where specified (e.g., WOMAC, HOOS, VCSS).

Required for many orthopedic and venous procedures.

Listing of a service in these guidelines does not by itself indicate that the service is covered or not covered. Benefit coverage is determined by federal, state, or contractual requirements and applicable law, and whether medical records/documentation support the clinical criteria for coverage. Providers should not assume that inclusion in these guidelines guarantees coverage; additional information may be requested to determine eligibility under the member’s benefit plan.

When high-quality color images or photographs are required to support a request (for example, cosmetic/reconstructive or gynecomastia reviews), images must be submitted electronically. Color images must be labeled with the date taken and either the applicable case number or the member’s name and ID, and must be uploaded via the external portal at uhcprovider.com/paan. Faxed images are not accepted for required color images.

For Negative Pressure Wound Therapy (NPWT), requests must show the wound is appropriate for NPWT. Wounds that are actively bleeding or have exposed vasculature, contain necrotic tissue, have exposed bone, nerves, or organs in the vicinity, have malignancy in the wound, present an open fistula to an organ or body cavity, or have uncontrolled soft tissue infection or osteomyelitis in the vicinity are contraindications and must be documented as absent before NPWT will be considered.

Diagnostic images and high-quality color photographs required for prior authorization or review must be submitted via the external portal; faxes will not be accepted. Failure to upload requested images through the portal may prevent completion of the review.

No additional explicit exclusions are stated in the provided excerpt beyond the procedure- or condition-specific contraindications noted elsewhere in these guidelines.

Within the excerpted content there are no explicit statements declaring particular services or procedures to be ‘‘not medically necessary.’strong

Relevant CPT/HCPCS codes and metrics

Electrical and Bone Growth StimulatorsHCPCS

E0747	Electrical Bone Growth Stimulator
E0748	Electrical Bone Growth Stimulator
E0749	Ultrasound Bone Growth Stimulator

Sleep study CPT codes with requirementsCPT

95811	PAP titration or split night study (sleep study) — request must indicate purpose
95805	Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) — documentation that other causes of excessive sleepiness have been excluded

Spinal cord stimulator trial pain relief threshold

Spinal cord stimulator trial pain relief threshold>= 50% reduction in pain from temporary implant

Supporting documentation requiredPercentage pain relief from temporary implant must be documented in medical record

Operative note requirementOperative notes for trial and permanent placement should be included when applicable

Sleep apnea severity metrics

Sleep apnea severity metrics to reportAHI, REI, or RDI values as reported in the sleep study

Sleep study results requiredResults of study confirming diagnosis and severity of OSA must be included in medical notes

Prior treatment documentationPrior treatments tried, failed, or contraindicated (including PAP intolerance) must be documented with dates and reasons

Procedure-specific dataFor surgical procedures, include procedure being requested and relevant anatomic findings (e.g., retrolingual obstruction, concentric collapse) when applicable

What providers must submit and actions to take

Prior Authorization

Breast reconstruction prior-authorization and pre-determination note

Mastectomy after a diagnosis of breast cancer does not require Prior Authorization/Advance Notification when a Pre-Determination is not being requested. If a pre-determination for breast reconstruction is requested, include diagnosis, history, imaging (when requested), surgical history (including implant type and dates), complications (e.g., capsular contracture with Baker grade and functional impairment), physician plan of care, and estimated volume of breast tissue to be removed per breast.

Pre-determination requests: provide diagnosis, history, surgical history, complications, images when requested, and surgeon consultation as needed.
Mastectomy for breast cancer: no prior authorization required unless pre-determination requested.

Documentation Required

Image submission and labeling requirement

For all cosmetic, reconstructive, gynecomastia, lesion, and related reviews requiring images, submit high-quality color photographs or diagnostic images labeled with the date taken and the applicable case number or the member's name and ID. Images must be uploaded via the external portal; faxes are not accepted.

Required labeling: date taken and applicable case number or member name/ID.
Submission method: external portal (www.uhcprovider.com/paan); faxes will not be accepted.

Documentation Required

Prior authorization documentation requirements

Prior authorization (when required) must include medical records demonstrating the history of the condition, pertinent physical exam findings, relevant diagnostic test results and imaging (with labeled images when requested), prior treatments or therapies tried/failed/contraindicated (with dates, durations, and reasons), and a physician plan of care that supports medical necessity.

Include relevant medical history, physical examination, and diagnostic test results.
Document prior therapies tried, failed, or contraindicated; include dates and reasons for discontinuation.
Provide physician plan of care and operative details when applicable.

Documentation Required

Photograph and diagnostic image submission

High-quality color photographs and diagnostic images are required for reviews of cosmetic/reconstructive procedures, gynecomastia, injectables, light/laser therapy, and many surgical requests. Photos/images must be labeled with date and case number or member name/ID and submitted through the external portal.

Photos for gynecomastia: frontal and lateral torso images and expected outcome views.
Images for lesion-based procedures: label with date and case number or member ID.

Prior Authorization

Sleep study prior-authorization details

For sleep study and sleep-related procedure prior authorizations, include the indication and specific details relevant to the CPT being requested (for example: for CPT 95811 indicate whether request is for PAP titration vs split-night study; for CPT 95805 include pertinent study details), diagnostic study results, face-to-face evaluation documentation, BMI and comorbid conditions, prior PAP therapy trials or intolerance, and other requested sleep-related diagnostics (e.g., Epworth score, prior studies).

Document type of sleep study requested and clinical indication.
Include prior sleep studies, PAP trial results, Epworth Sleepiness Score, and relevant comorbidities.

Documentation Required

Image submission, labeling, and portal requirement

If diagnostic images are requested, submit the original image files (not just reports) labeled with the date taken and the applicable case number or member name/ID via the external portal. Failure to submit required labeled images or photos via the portal (faxes are not accepted) may prevent completion of the review or adversely affect the decision.

Images must be labeled with date and applicable case number or member name/ID.
Upload images through the external portal; faxes will not be accepted.

Denial Risk

Insufficient documentation risk

Insufficient or incomplete medical record documentation that does not fully support the medical necessity of the requested service may result in additional review time, a pend for records request, or denial. Make sure records are legible and made available upon request.

Incomplete documentation may trigger denial or delay.
Records must be legible and available upon request.

Documentation Required

General medical record and service-specific documentation expectations

Maintain and submit comprehensive medical records to support all requests: relevant history, focused physical exam findings, diagnostic test results (including imaging and reports), prior treatments or therapies (with dates and outcomes), medication lists, and the treating physician's plan of care. For many procedures include procedure-specific documentation (operative reports, device make/model, comparative plans for radiation modalities, wound measurements, debridement dates, etc.).

Provide operative notes and percentage pain relief for spinal cord stimulator permanent placement (≥50% relief from trial).
For IMRT and Proton Beam Therapy include comparative treatment plans and dose-volume histograms when requested.
For NPWT include wound stage, size, type, debridement dates, start date and prior outcomes.

Documentation Required

Continuous Glucose Monitoring and insulin delivery documentation

Continuous Glucose Monitoring (CGM) and insulin delivery requests must include the member's current diabetes type, recent lab results and office notes (within 3 months for initial requests; within 6 months for renewals), treatment plan, frequency/severity of hypoglycemia (for CGM), current signed physician order, and the make/model of the device requested.

CGM initial requests: labs/office notes within 3 months, hypoglycemia history, signed order, device make/model.
CGM continued use: assessment and labs within 6 months, adherence documentation, signed order.

Documentation Required

Gynecomastia-specific documentation

Gynecomastia surgery requests require a detailed history (including medication and substance screening), documentation of functional or physiological impairment, frontal and lateral high-quality color photographs of the torso labeled with date and case number or member name/ID, relevant lab/imaging results (e.g., mammography, hormone testing, liver enzymes), and a treatment plan. Photographs must be submitted via the external portal; faxes will not be accepted.

Provide medication and substance use screening (including anabolic steroids, cimetidine, etc.).
Submit frontal and lateral color photos labeled with date and case number or member name/ID via the portal.

Documentation Required

Spinal cord stimulator documentation specifics

For spinal cord stimulator permanent placement requests, include whether the request is for a trial or permanent device; for permanent placement submit operative notes and documentation that the trial produced at least 50% pain relief and describe the procedural details.

Trial documentation must show ≥50% pain relief to support permanent implant.
Provide operative notes and details of lead placement, device type, and any complications.

Documentation Required

IMRT documentation and comparative planning

Requests for Intensity-Modulated Radiation Therapy (IMRT) should include the specific condition and target volume, prior radiation history (sites, total dose, dose per fraction), a justification that IMRT is required versus conventional/3D techniques, and when applicable a clearly labeled, color comparative 3D and IMRT plan with dose-volume histograms and dose tables in absolute doses. Cite RTOG protocol numbers when referencing RTOG dose constraints.

Provide prior radiation details and explain need for IMRT vs other techniques.
Submit comparative treatment plans and dose-volume histograms when requested; include RTOG protocol number if applicable.

Documentation Required

Private Duty Nursing documentation

Private Duty Nursing requests must include a Home Health Certification (CMS-485) with a physician-signed Plan of Care (or appropriately signed by advanced practitioner per law) and a clinical assessment specifying the days and hours of private duty nursing requested and the clinical rationale.

Include CMS-485 with Plan of Care signed by physician or authorized advanced practitioner.
Provide clinical assessment detailing days/hours of care requested and specific clinical needs.

Documentation Required

Prior therapies and conservative treatment documentation

When prior conservative therapies or other prior treatments are relevant to the requested service (e.g., spine injections, neuromodulation, venous/vascular procedures, bariatric history, airway devices), document therapies tried, dates, duration, response, and reasons for discontinuation or contraindication. Many reviews require structured prior-therapy notes.

List prior pharmacologic, physical therapy, device trials, behavioral interventions, or surgeries with dates and outcomes.
If therapies were contraindicated, document the rationale.

Documentation Required

Proton Beam Therapy comparative planning and documentation

For requests involving advanced modalities (e.g., Proton Beam Therapy), include comparative treatment planning showing that normal tissue sparing cannot be achieved with IMRT/SBRT, color comparative dose-volume histograms and dose tables, prescribed total dose and dose per fraction (for hypofractionation), and the physician's treatment plan. Cite RTOG protocol numbers when applicable.

Provide PBT vs IMRT vs SBRT comparative plans and documentation that normal tissue sparing is superior with PBT.
Submit clearly labeled color comparative dose-volume histograms and dose tables in absolute doses.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Records Documentation Used for Reviews: Community Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit complete, legible medical records and labeled diagnostic images/photos via the external portal to support prior authorization reviews.

SourceLink

On This Page

Prior treatments: Prior therapies or treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation.

Required for many sections including venous, spine, VNS, TARE and others.

Procedure-specific items: Procedure-specific documentation such as device name for transcatheter valves, NYHA class and valve gradients for aortic procedures, PROM scores for valve-in-valve, VCSS for venous disease, ECOG and resection feasibility for TARE, psychosocial/behavioral notes and instability documentation for lumbar spine, and operative reports when applicable.

See section-specific lists in the policy for detailed required elements.

Inpatient site of care support: If an inpatient stay is requested, documentation must support the site of care (examples: bilateral surgery, significant comorbidities, lack of post-operative support).

Applies when inpatient location is requested.