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 a wide range of services for UnitedHealthcare Community Plans; applies to providers submitting requests for services in the listed states and 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 ActionWhen requesting review/authorization, submit complete medical records that document history, exam, diagnostics, prior therapies (with dates/duration/reasons), and any service-specific items (e.g., labeled imaging, photos, device details) via the external portal when requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice categories (partial TOC)

20+distinct service sections in excerpt

11applicable states listed

history/exam/diagnosticscommon documentation items

portal required

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portal required for images

Documentation Requirements to Support Medical Necessity

General documentation to support medical necessity

Covered when documentation fully supports medical necessity as described below

General requirement: The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation must be legible, maintained in the patient record, and made available upon request.

Bariatric surgery initial request — ALL required elements

Initial bariatric surgery requests must include ALL of the following

Bariatric initial: Height; Weight; Current and five-year history of BMI; Diet history; Comorbidities; Medical treatment tried and failed including diet and exercise; Psychological evaluation by a licensed behavioral health professional; Nutritional consult; Name of the facility where the procedure will be performed.

Additional documentation required for subsequent bariatric surgery.

Beds and mattresses (DME) documentation — required items for DME bed/mattress requests

Applicable items when requesting beds/mattresses

Bed/mattress documentation: Current prescription including initial/ongoing/replacement and rental or purchase; specific HCPCS codes for each item and accessory; equipment make, model and price quote; if replacement, date of acquisition and warranty status; diagnosis and functional limitations; member weight/height; reason standard bed is inadequate; prior approaches tried/failed.

Include physician treatment plan.

Breast reconstruction and reduction — documentation when pre-determination or reduction requested

When pre-determination is requested or for breast reduction documentation

Breast reconstruction/reduction documentation: Diagnosis; history and surgical history; recent imaging reports and diagnostics (labeled); for CPT 19370 and 19371 submit high-quality color photographs labeled with date and case number or member ID; physician plan of care; for reductions include photos and documentation of functional impairments and physical exam including height and weight.

Images/photos must be submitted via the external portal; faxes not accepted.

Brow ptosis and eyelid repair — documentation required when applicable

Documentation required when applicable

Ophthalmic procedure documentation: History of condition; visual complaints and functional impairments interfering with ADLs; eye exam including best corrected visual acuity; treatments tried/failed with dates and reasons; recent diagnostic testing including automated visual fields with percent/degree improvement or explanation why testing is not feasible; marginal reflex distance (MRD-1); high-quality labeled photographs (full face frontal and lateral).

Submit color photos via portal when requested; faxes not accepted.

Catheter ablation for atrial fibrillation — documentation to support AF ablation requests

Documentation to support AF ablation requests

AF ablation documentation: Diagnosis documented by ECG, Holter, or rhythm strip; a recent physical exam within the last 3 months; signs and symptoms including onset, duration, frequency and whether symptomatic, paroxysmal, or persistent; reports of recent imaging and diagnostics including electrolytes within 6 months, TSH within 12 months, ischemia assessment within 12 months, and left ventricular ejection fraction by echocardiography or MUGA; treatments tried/failed/contraindicated with dates, duration and reason for discontinuation; physician treatment plan.

Service-specific documentation criteria — service-specific lists across multiple procedures

Covered when the medical record includes the service-specific documentation items listed below

General record elements: Medical history, physical examination, and results of pertinent diagnostic tests or procedures must be documented and legible in the patient medical record and made available upon request.

Applies across services

Service-specific documentation (examples): Each service section lists required supporting items (e.g., diagnosis, treatment history, imaging reports, device make/model, physician treatment plan, prior therapies tried/failed/contraindicated with dates), which must be present to support medical necessity.

See individual service entries in the document for details

General medical records criteria — overarching list of required elements for procedures

Covered when medical record contains all applicable documentation items listed for the specific procedure

General documentation elements: Relevant medical history; pertinent physical exam of the relevant joint/area; reports of imaging and diagnostic tests (labeled with date and case/member identifiers when requested); documentation of prior therapies/treatments tried, failed, or contraindicated including dates, duration, and reason for discontinuation; physician's treatment plan including pre-op discussion; for revisions, details of complication and complete staged surgical plan; if inpatient stay requested, documentation to support site of care.

Applies across multiple procedure sections.

Venous insufficiency procedural criteria — specific items for venous/varicose procedures

For surgical and ablative procedures for venous insufficiency and varicose veins, include the following specific items

Venous-specific items: Diagnosis; history including DVT, aneurysm, tortuosity, and prior vein procedures; signs and symptoms with onset/duration/frequency and which extremity is affected; pain or other symptoms interfering with ADLs; validated functional disability score (e.g., VCSS or VDS); physical exam specifying extremity and vein(s) to be treated; vein diameter and anatomic location of measurement; duration of reflux and measurement location; recent imaging and diagnostic reports; prior therapies tried/failed/contraindicated with dates and reasons; proposed treatment plan with procedure code and specific veins and laterality.

Used to assess necessity for venous procedures.

Total artificial disc replacement criteria — documentation required for cervical/lumbar disc replacement

For total artificial disc replacement (cervical or lumbar), include

Disc replacement items: Diagnosis and specific procedure requested; levels of motor and sensory deficit; extremity weakness, numbness, pain or loss of dexterity; gait disturbance and workup; bowel or bladder dysfunction and workup; history/signs of infection, malignancy, facet arthritis or instability at the requested level; detailed neurologic physical exam; relevant medical/surgical history (e.g., osteoporosis/osteopenia, spondylosis severity, ankylosing spondylitis, rheumatoid arthritis, OPLL, fractures); relevant imaging and documentation of instability; treatments tried/failed with dates/duration/reasons; current medications with start dates; physician treatment plan including surgical technique and number of levels.

Imaging must be labeled and may be requested to be submitted via portal.

Transcatheter valve procedure criteria — documentation required for valve procedures

For transcatheter valve procedures, documentation must include

Transcatheter valve items: Name of device if available; diagnosis and comorbidities; treatments tried/failed/contraindicated with dates, duration and reasons; physician treatment plan and facility; for aortic valve procedures include NYHA class and one of mean aortic valve gradient, peak aortic jet velocity, or aortic valve area and evidence of shared decision-making with interventional cardiologist and cardiothoracic surgeon; for valve-in-valve include name of failed device and PROM surgical risk score; for mitral or other valves include MR/TR grade, NYHA class, PROM score and composition of the care team; provide procedure-specific hemodynamic metrics as appropriate.

Procedure-specific hemodynamic and risk data required.

Vertebral body tethering criteria — documentation required for scoliosis tethering

For vertebral body tethering for scoliosis, documentation must include

VBT items: Condition requiring procedure; signs and symptoms; treatments tried/failed/contraindicated with dates, duration and reason including failed external bracing or documented intolerance despite reasonable efforts; evidence of shared decision-making with a pediatric orthopedic spine surgeon; recent imaging with standing PA and lateral and traction/bending radiographs, Cobb angle, and Sanders skeletal maturity staging; name of the facility where procedure will be performed.

Specific imaging metrics required for candidacy.

Listing a service in these guidelines does not itself imply that the service is covered or not covered. Benefit coverage is determined separately by federal, state, contractual requirements, and applicable law. The documentation listed is used to assess whether a member meets clinical criteria for coverage, but submission of records alone does not guarantee coverage.

No additional explicit coverage criteria are stated in these referenced chunks beyond the general requirement that medical records must support medical necessity and that labeled high-quality images and service‑specific documentation may be requested when applicable.

When color photographs or diagnostic images are requested, they must be submitted via the external portal at www.uhcprovider.com/paan. Faxes will not be accepted for required color photographs or diagnostic image submissions when portal submission is requested; images must be labeled with date and the applicable case number or member identifiers.

Certain wounds are contraindications or require special handling for negative pressure wound therapy (NPWT). Examples include wounds with active bleeding, exposed vasculature, necrotic tissue, exposed bone/nerves/organs in the wound vicinity, malignancy present in the wound, an open fistula to an organ or body cavity, or uncontrolled soft tissue infection or osteomyelitis in the area; these conditions must be documented and considered when evaluating NPWT requests.

When diagnostic images are requested as part of an authorization or review, they must be submitted via the external portal at www.uhcprovider.com/paan. Diagnostic images submitted by fax will not be accepted when portal submission is requested; required images should be labeled with the date taken and case or member identifiers.

There are no other explicit coverage exclusions or criteria stated in these referenced chunks beyond the detailed documentation requirements and Community Plans applicability described elsewhere in the document.

Failure to provide the medical record documentation that fully supports medical necessity may prompt requests for additional information and can delay or jeopardize the coverage decision. Incomplete or missing supporting documentation may ultimately lead to a determination that the service is not medically necessary if the record does not substantiate the request.

The excerpts emphasize the specific documentation items required to support requests (history, physical exam, imaging/labeled photos, prior treatments tried/failed with dates and reasons, device details, prescriptions, and physician treatment plan). They focus on required supporting documentation rather than listing discrete not‑medically‑necessary conditions.

Requests that lack the required supporting documentation — including relevant history, focused physical exam, imaging and diagnostic test reports, and records of prior therapies with dates, duration and reasons for discontinuation — may be delayed or denied because reviewers cannot complete the medical necessity assessment without those elements.

Procedure, HCPCS, and CPT Code Guidance

DME/Equipment HCPCS CodesHCPCS

HCPCS code(s)

Specific HCPCS codes for item and each accessory requested (as applicable)

Breast reconstruction CPT codes requiring photosCPT

CPT 19370	Breast reconstruction/relevant CPT referenced for photo submission
CPT 19371	Breast reconstruction/relevant CPT referenced for photo submission

HCPCS codes for DME and device requestsHCPCS

HCPCS

Specific HCPCS code(s) for item and each accessory requested (documented in DME/mobility device and speech generating device sections)

Hip arthroscopy CPT codes for FAICPT

29914	Arthroscopy, hip, surgical; with femoroplasty (separate codes listed in text)
29915	Arthroscopy, hip, surgical; with acetabuloplasty
29916	Arthroscopy, hip, surgical; with labral repair

inv-27: BMI documentation for bariatric surgery — current and 5-year BMI history

Required BMI entriesCurrent BMI and documented five-year BMI history (height and weight records) must be provided for initial bariatric surgery requests.

Supporting historyDiet history and comorbidities must be documented alongside BMI data.

Treatment attemptsMedical treatments tried and failed including diet and exercise should be listed with dates/duration and reasons.

Behavioral and nutrition evaluationsPsychological evaluation by a licensed behavioral health professional and a nutritional consult must be included.

Facility nameName of the facility where the procedure will be performed must be provided.

What Providers Must Submit and How to Avoid Denials

Documentation Required

Required medical records and documentation

Provide complete, legible medical records that fully support medical necessity for the requested service. Records should include: relevant history, physical examination findings, diagnostic test results and reports, prior therapies (dates, duration, reason for discontinuation), and the physician's plan of care. Documentation must include provider name, specialty, and signature/date. Failure to provide required documentation may delay review or result in denial.

Include prior treatments tried/failed or contraindicated with dates, duration, and reason for discontinuation
Include relevant diagnostic testing and reports (imaging, labs, sleep studies, ABGs, PFTs, EMG, EEG, etc.)
Physician treatment plan and expected functional improvement

Documentation Required

Diagnostic image and photograph submission method

For procedures or devices requiring images or photographs, submit high-quality, labeled images via the external image portal at www.uhcprovider.com/paan when requested; faxes will not be accepted. Label each image/photo with the date taken and the applicable case number or the member’s name and ID number. Failure to submit required labeled diagnostic images or photographs via the portal may prevent completion of the review and lead to denial.

Policy Purpose and Scope

This document compiles the medical record elements UnitedHealthcare reviewers commonly use to assess medical necessity across many services for Community Plans. The purpose is to standardize the items reviewers may request so providers can submit complete records and reduce repeated information requests, improving turnaround time for coverage decisions.

Key Terms and Outcome Metrics

inv-81: Medical records documentation used for reviews — definition of 'medical records' elements reviewers may require

DefinitionMedical records used for reviews are the set of medical notes, diagnostic results, images, and other documentation reviewers may require to determine if requested services meet clinical criteria.

Core elementsRelevant medical history, physical examination, and results of pertinent diagnostic tests or procedures must be included and legible.

Service‑specific itemsInclude service-specific attachments when applicable (e.g., labeled imaging, high-quality photographs, HCPCS/CPT codes, device make/model, vendor quotes).

AvailabilityDocumentation must be maintained in the patient record and made available upon request; the reviewer may request additional information.

inv-82: Percentage of pain reduction — outcome metric used in pain procedure reviews

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

SourceLink

On This Page

inv-28: Cobb Angle — documented Cobb angle on recent imaging for scoliosis procedures

Required Cobb angleDocumented Cobb angle on recent standing PA/lateral and bending/traction radiographs must be provided for vertebral body tethering and scoliosis procedures.

Associated imagingRecent imaging reports and radiologist report including the specific films used (standing PA and lateral, bending) should accompany the Cobb angle.

Skeletal maturityInclude Sanders skeletal maturity staging alongside Cobb angle for candidacy assessment.

Contextual detailsProvide indication/condition requiring procedure, signs/symptoms, and prior treatment history with dates (e.g., failed external bracing).

inv-29: NYHA Classification / valve metrics — required metrics for aortic valve procedures

NYHA classificationDocument the patient's New York Heart Association (NYHA) class for aortic valve replacement evaluations.

Aortic valve hemodynamics (one required)Provide one of: mean aortic valve gradient, peak aortic jet velocity, or aortic valve area.

Shared decision-makingEvidence of a shared decision-making conversation with an interventional cardiologist and an experienced cardiothoracic surgeon should be documented.

Device and risk dataName of device if available and, for valve-in-valve, the name of failed device and PROM surgical risk score should be provided.

Treatment history and planDocument comorbidities, treatments tried/failed/contraindicated with dates/reasons, and the physician treatment plan and facility.

Diagnostic images (MRI, CT, X-ray, CTA, MRA, ultrasound, etc.) must be labeled with date and case number/member identifiers
High-quality color photographs for selected services (e.g., breast reconstruction, breast reduction, panniculectomy, rhinoplasty, gynecomastia, liposuction for lipedema) must be labeled and submitted via the portal

Documentation Required

Prescription/Order and HCPCS codes required

When a prescription/order or HCPCS/CPT code is required (commonly for DME, orthotics, prosthetics, compressors, beds, and device requests), include a current signed physician order that specifies whether the request is initial, replacement, or ongoing, the HCPCS/CPT code(s), and device make/model and manufacturer when available. For DME and pneumatic/complex devices list accessories, settings, and anticipated hours of use.

Current signed physician order (initial, ongoing, or replacement)
Specific HCPCS/CPT code(s) for the item and each accessory requested
Equipment make, model, price quote (if available) and justification for requested features

Documentation Required

Prosthetic prior authorization documentation

For prosthetic requests (upper and lower extremity, off-the-shelf and custom), supply detailed documentation to support medical necessity: vendor coversheet and invoice listing HCPCS codes, make/model and laterality; prosthetist notes with medical justification for each component; physician notes describing functional limitations, residual limb status, comorbidities, rehabilitation plan and whether request is initial, preparatory, definitive or replacement. For replacements include age of current prosthesis, reason for replacement, and comparative residual limb measurements if socket replacement.

Vendor coversheet and invoice with HCPCS codes and make/model
Prosthetist notes and physician documentation of residual limb exam, ADL limitations, and rehab potential
If replacement: age of current device, warranty status, and reason for replacement

Prior Authorization

Implanted electrical devices — documentation for authorization

For implanted electrical devices (e.g., spinal cord stimulator, DRG, sacral nerve stimulator, vagus), document whether the request is for trial or permanent implantation. Provide trial data including percentage pain reduction, operative notes from trial (and permanent) procedures, detailed history/physical, prior conservative therapies tried and failed (with dates), comorbidities, mental health/substance use history, and the physician plan of care. For revision or removal include details of complication and complete treatment plan.

Indicate trial versus permanent placement and % pain reduction for trials
Operative notes for trial and permanent implantation with outcomes
Prior therapies/medications tried and dates, and mental health/substance use history

Prior Authorization

IMRT — prior authorization requirements

For intensity-modulated radiation therapy (IMRT) and other specialized radiation services, include: diagnosis and specific target volume, history of prior radiation (sites, total dose, dose per fraction), a statement explaining the special need for IMRT vs conventional/3D techniques, and when applicable submit dose prescriptions and clearly labeled color comparative plans (3D vs IMRT) with dose-volume histograms and dose tables in absolute doses. Cite applicable protocol (RTOG/Quantec) for dose constraints when referenced.

Specific target volume and rationale for IMRT
Prior radiation history with site(s), total dose and dose per fraction
Color comparative 3D and IMRT plans with DVH and dose table when requested

Documentation Required

Pain-procedure specific documentation

For pain-procedure requests (injections, facet/medial branch blocks, radiofrequency ablation, epidural injections), include a clear diagnosis, history of the condition and prior conservative treatments tried and failed (dates and duration), physical exam findings (including facet loading maneuvers when relevant), imaging reports, and the physician plan with proposed location(s) (side and level) and imaging guidance plan (fluoroscopy, CT, ultrasound). For subsequent injections provide documentation of response to prior injection(s) including level, side, date and duration of benefit (percentage pain reduction when available).

Location (side/level) of proposed injection and guidance modality
Conservative treatments tried/failed with dates and objective response
Response to prior injections (level, side, date, duration of effect, % pain reduction)

Documentation Required

Photograph and pre-op documentation requirements

Provide photographic and pre-operative documentation for procedures where required (for example: breast reconstruction codes 19370/19371, breast reduction, macromastia, gynecomastia, panniculectomy, rhinoplasty). Photos must be high-quality color images labeled with date and case number or member identifiers and submitted via the external portal. Include pre-op notes and physician plan of care describing how the procedure will improve or restore function.

High-quality color photographs labeled with date and case number/member ID
Physician plan of care and whether request is part of a staged procedure

Documentation Required

Cranial orthotic documentation

For cranial orthotic requests document current prescription, diagnosis and indication, neurological/circulatory/skin/musculoskeletal exam including presence/absence of torticollis, and objective cranial measurements (e.g., CVAI, CI, TDD, CVA). Provide documentation of conservative measures tried (repositioning, therapy), orthotist notes with anthropometric measurements, equipment quote with billing codes, and compliance/wear data. For continuation/ replacement requests include age of current orthotic and reason for replacement.

Prescription and objective cranial measurements (CVAI, CI, TDD, CVA)
Orthotist notes, equipment quote with billing codes, and compliance with wear

Prior Authorization

Panniculectomy documentation

For panniculectomy requests include primary complaint and history, grade of panniculus, BMI and recent weight-loss history with stability/duration, dermatologic complications and treatments (dates and outcomes), functional limitations interfering with ADLs, relevant surgical history, physician treatment plan, and, upon request, high-quality labeled color photographs (full-frontal hanging pannus, elevated pannus showing skin damage, full lateral view) submitted via the portal.

BMI, grade of panniculus, recent weight loss and duration of weight stability
Documented dermatologic complications and treatments tried/failed
Labeled high-quality photos of pannus submitted via portal when requested

Prior Authorization

Vertebral body tethering documentation

For vertebral body tethering include condition requiring procedure, signs and symptoms, documentation of prior treatments tried/failed (including failed external bracing or intolerance with dates), shared decision-making documentation with a pediatric orthopedic spine surgeon, standing and bending radiographs with Cobb angle and Sanders skeletal maturity stage, radiology report, facility and surgeon information, and IRB protocol/enrollment when applicable. For revisions include reason for revision.

Evidence of failed external bracing or intolerance and dates
Standing PA and lateral radiographs, traction/bending films, Cobb angle, Sanders stage
Shared decision-making notes and surgeon/facility details

Documentation Required

Prior conservative treatments documentation

Document prior conservative treatments where required: examples include padding, orthotics, footwear modifications, physical therapy, activity modification, bracing, pharmacologic therapy, topical agents, and attempts at smoking cessation for peripheral vascular disease. For each conservative therapy document dates, duration, objective response, and reason for discontinuation or contraindication. Lack of documented conservative management when required may result in denial.

List conservative measures tried with dates and duration
Objective response and rationale for discontinuation or contraindication

Prior Authorization

Neuromodulation prior therapy documentation

For neuromodulation (vagus, external trigeminal, deep brain, cortical stimulation, sacral nerve, spinal cord stimulators), document pharmacologic therapies and other stepwise management tried/failed (names, doses, dates), prior surgeries, seizure or symptom frequency, response to prior treatments, candidacy for other surgical options, and detailed history/physical. For permanent implantation include objective improvement from trial period and documentation of the individual's ability to operate/manage the device.

List of pharmacologic agents and other therapies tried and failed with dates
Operative and trial notes with percent improvement and functional outcome measures
Assessment of candidacy for alternative surgical treatments

Percentage of pain reduction documents the relative improvement in pain reported after an intervention or trial and is used in pain procedure reviews.

Context of useRequired for pain procedures such as facet/medial branch injections and spinal cord stimulator trials to document response to intervention or trial.

Documentation detailsRecord pre- and post-procedure pain scores (e.g., 1–10 scale) and duration of effect, with dates and levels/sides for injections.

inv-83: VCSS / VDS — venous disease functional disability scales referenced for venous procedures

VCSS/VDS useValidated functional disability scales (e.g., Venous Clinical Severity Score or Venous Disability Score) are used to document functional impairment from venous disease that interferes with standing or sitting.

When to includeInclude a validated score when submitting requests for surgical or ablative procedures for venous insufficiency and varicose veins.

Accompanying detailsProvide accompanying history, signs/symptoms, extremity laterality, vein(s) to be treated, vein diameter and location, duration of reflux, and recent imaging.

inv-84: Tönnis or Outerbridge grading — radiographic grading systems for cartilage damage referenced in hip procedures

Grading systemsTönnis or Outerbridge grading are radiographic grading systems used to report severity of cartilage damage for femoroacetabular impingement and hip procedures.

Documentation roleInclude the applicable radiographic grade in imaging reports submitted to support hip procedure requests (e.g., hip arthroscopy for FAI).

Imaging requirementsProvide labeled imaging studies and reports that show the cartilage damage and correlate with clinical exam and treatment history.

inv-85: Replacement prosthesis — definition and required documentation elements (age, reason, repair attempts)

DefinitionA replacement prosthesis is a requested prosthesis intended to replace an existing prosthesis; documentation must demonstrate the need for replacement.

Required replacement detailsProvide age of the current prosthesis and the reason for replacement (including functional issues or device failure).

Repair/adjustment costInclude estimated cost of adjustment or repair if applicable when requesting replacement versus repair determination.

Socket replacement specificsFor socket replacement include age of current socket, reason for replacement, and comparative residual limb measurements showing change in limb size.

Comprehensive prosthetic documentationAlso include physician notes, prosthetist justification for components, rehabilitation plan, and whether request is initial, replacement, preparatory, definitive or upgrade.

inv-86: Reanalysis (genetic testing) — definition and required info for reanalysis of exome/genome testing

Definition of reanalysisReanalysis is a subsequent analysis of previously performed whole exome or whole genome testing and requires the date of the initial testing.

Triggering informationProvide new data or new symptoms since the last analysis to justify reanalysis.

Core supporting recordsInclude original testing results, all relevant prior diagnostic/genetic testing results and dates, and how reanalysis results will impact clinical management.

Ordering providerDocument the name and specialty of the provider ordering the reanalysis.