CurrentUnitedHealthcarePolicy N/A

Medical Records Documentation Used for Reviews

This document lists medical record items that may be required by UnitedHealthcare when reviewing requests for coverage across many clinical services; it guides providers on documentation to support prior authorization and medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Records Documentation Used for Reviews

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit complete medical notes and labeled diagnostic images via the external portal when requested to support prior authorization reviews.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>60service categories listed in Table of Contents

~20+distinct services or device types with specific documentation lists in this excerpt

6 monthsface-to-face encounter recency required for some DME prescriptions

portal-onlydiagnostic images must be labeled and portal submission required (no faxes)

detailedNPWT detailed contraindications listed

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Coverage Criteria by Service

Negative Pressure Wound Therapy documentation criteria

Covered when documentation includes the following supporting elements:

NPWT required documentation: Diagnosis; history of the medical condition requiring NPWT; recent physical exam; signs and symptoms; treatments tried, failed, or contraindicated with dates, duration and reasons for discontinuation; wound stage, size, location and measurements; wound type (post-surgical, venous stasis, decubitus ulcer, diabetic neuropathic ulcer); date(s) of surgery including debridement; date NPWT (wound VAC) was started; evidence that a favorable wound environment has been maintained (appropriate dressing changes, adequate nutrition, incontinence management if applicable); absence of exclusionary wound conditions (active bleeding or exposed vasculature in the wound; necrotic tissue; exposed bone, nerves or organs in vicinity of wound; malignancy present in wound; open fistula to an organ or body cavity within vicinity of wound; uncontrolled soft tissue infection or osteomyelitis within vicinity of wound); if diabetic, documentation of enrollment in a diabetic management program; documentation of turning/repositioning for Stage III or IV pressure ulcers; and, if applicable, documentation when NPWT has been used previously on the same type of wound with a favorable clinical response.

All listed items are requested when applicable.

Pneumatic compression device coverage documentation

Covered when ALL of the following are provided:

Pneumatic compression device criteria: Current physician prescription (written order) indicating initial/ongoing/replacement and rental vs purchase; specific HCPCS code(s) for the item and each accessory requested; equipment make, model and price quotation; justification for why the features of the device are needed; if replacement, current device used, date of initial acquisition, warranty status and reason for replacement; member diagnosis and affected anatomical site when applicable; member symptoms and ambulation status; treatments tried, failed, or contraindicated with dates, duration and reasons for discontinuation; member or caregiver willing and able to manage device; treatment plan including pressure in each chamber, frequency and duration of each treatment; inclusion in ongoing decongestive therapy program, wound care, or edema management; education regarding monitoring schedule and treatment response; and for ongoing use include documentation of proper use and continued benefit.

Device-specific HCPCS codes and equipment quote required.

Private Duty Nursing coverage documentation

Covered when ALL of the following are included in request:

Private duty nursing criteria: Home Health Certification (CMS-485) including the Plan of Care signed by a physician (M.D. or D.O.) or an authorized advanced practitioner in accordance with applicable law/regulation; clinical assessment specifying days and hours of private duty nursing requested (e.g., 8 hours/day x 5 days/week) and details if request is post-inpatient discharge; caregiver status and availability (willingness to participate, hours in the home, work schedule, ability to learn and provide care); consultation notes from subspecialists if applicable; complete Medication Administration Record; physician-ordered clinical assessments documenting need and frequency for skilled nursing tasks such as tracheostomy care and airway status, respiratory support (oxygen therapy, NIPPV), mechanical ventilator status and weaning documentation if applicable, need for nasal/oral suctioning, nebulizer treatments, high-frequency chest wall oscillation, chest therapy, blood draws, and feeding.

Private duty nursing operational note: Physician signature requirements must meet applicable law/regulation for the plan of care.

Obstructive sleep apnea treatment documentation

Covered when documentation includes:

OSA treatment criteria: Diagnosis of obstructive sleep apnea; current evaluation by a physician or advanced practice provider working under direct physician supervision; current written order for initial oral appliance or replacement (if replacement, include current device used and reason for replacement); signs and symptoms and comorbidities; results of sleep study including severity metrics (AHI, REI, or RDI values); documentation of prior treatments tried, failed, or contraindicated with dates, duration and reason for discontinuation, including documentation of PAP intolerance, refusal, or lack of therapeutic efficacy; and for requested surgical procedures include the specific procedure, relevant imaging/diagnostic reports (e.g., Epworth Sleepiness Scale), and procedure-specific anatomic or BMI details as applicable (e.g., presence/absence of retrolingual or lower pharyngeal obstruction for mandibular osteotomy; evidence of craniofacial disproportion for maxillomandibular osteotomy; BMI for implantable hypoglossal nerve stimulation).

Adolescent Down Syndrome cases require additional Down Syndrome–specific information when applicable.

Mastectomy performed after a diagnosis of breast cancer does not require Prior Authorization/Advance Notification. This note applies to the coverage workflow and does not change any clinical requirements; other documentation may still be requested if a pre-determination is submitted for related services such as breast reconstruction.

When high-quality color photographs are required (for example, gynecomastia or other procedures noted in this policy), images must be submitted via the external portal at www.uhcprovider.com/paan. Faxes will not be accepted. All photos should be labeled with the date taken and the applicable case number or the member's name/ID.

Negative Pressure Wound Therapy (NPWT) is inappropriate and should not be used when the wound demonstrates any of the following exclusionary conditions: active bleeding or exposed vasculature, necrotic tissue, exposed bone/nerves/organs, malignancy present in the wound, an open fistula to an organ or body cavity, or uncontrolled soft tissue infection or osteomyelitis. Requests for NPWT must document absence of these conditions along with the required wound history and prior therapies.

When diagnostic imaging is requested as part of a prior authorization review, submission of the actual image files must be done via the external portal at www.uhcprovider.com/paan. Faxes will not be accepted. Images should be clearly labeled with the date taken and the applicable case number or the member's name/ID to avoid delay or denial.

Coding and Code References

HCPCS codes (general requirement)HCPCS

Specific HCPCS codes required

Request must list specific HCPCS code(s) for item and each accessory requested

Device HCPCS codesHCPCS

HCPCS codes

Specific HCPCS code(s) required for pneumatic compression devices and requested accessories (provider must supply exact codes).

Referenced CPT codesCPT

95805

Multiple Sleep Latency Testing (MSLT) — notes should indicate MSLT/MWT specifics as requested.

Sleep study severity metrics — key values for AHI/REI/RDI to display prominently

Required sleep severity metricsAHI, REI, or RDI values reported from the sleep study to indicate OSA severity

Sleep study result contextResults must confirm diagnosis and severity of obstructive sleep apnea for oral appliance or surgical requests

Prior treatment documentation linked to metricsInclude prior treatments tried/failed or contraindicated (with dates/duration/reasons) alongside sleep severity values

Provider Submission Requirements and Action Items

Prior Authorization

Prior authorization and incomplete documentation

Prior authorization/pre-determination information: UnitedHealthcare may require prior authorization or pre-determination for many services. Incomplete or missing documentation may delay the review or result in denial. When a pre-determination is requested, follow any service‑specific notes in this section (for example, breast reconstruction).

Pre-determination required where noted in specific clinical sections (e.g., some cosmetic/reconstructive requests).
Call the number on the member ID card for radiology referrals.

Documentation Required

DME prior authorization documentation

Durable Medical Equipment (DME) requests must include a current written prescription (physician order) and specific HCPCS code(s) for the item and each accessory. Include make/model, price quote, and whether the request is initial, ongoing, replacement, rental, or purchase. For replacements, provide age of current device, warranty status, reason for replacement, and prior payer when available.

Background and Scope

This document provides the clinical and administrative documentation UnitedHealthcare may require to evaluate medical necessity and process prior authorization requests across a broad range of services. It lists, by service type, the typical medical record elements requested — including diagnosis and history, relevant physical exam findings, prior treatments tried/failed (with dates and reasons), and applicable diagnostic testing or imaging. For certain services the policy requires additional items such as labeled diagnostic images or high-quality color photographs submitted via the external portal, evidence of prior conservative therapies, device make/model and HCPCS codes, and objective functional measures when applicable. Providers should submit the requested records and labeled images through the specified portal to prevent delays or denials.

Definitions and Key Terms

HH Certification (CMS-485) — home health certification requirement

HH Certification (CMS-485) requirementPhysician-signed home health certification (CMS-485) including a plan of care is required for private duty/home health review

Plan of care detailsCMS-485 must include clinical assessment specifying days and hours requested and whether service is post-discharge

Physician signature and authorityPlan of care must be signed by an authorized clinician per applicable law/regulation

NPWT exclusions — conditions that contraindicate Negative Pressure Wound Therapy

Active bleeding or exposed vasculatureNPWT is contraindicated when the wound has active bleeding or exposed vasculature

Necrotic tissue or exposed structuresNPWT is not appropriate when necrotic tissue or exposed bone, nerves, or organs are present in the wound vicinity

Policy Summary

PayerUnitedHealthcare

PolicyMedical Records Documentation Used for Reviews

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit complete medical notes and labeled diagnostic images via the external portal when requested to support prior authorization reviews.

SourceLink

On This Page

Current prescription (written order) from the treating practitioner.
Specific HCPCS code(s) for item and each accessory requested.
Equipment make, model and price quotation.
If replacement: date of initial acquisition, warranty status, components/serial number, and reason for replacement.

Prior Authorization

Sacroiliac / Sacral nerve stimulation prior authorization info

Sacroiliac (SI) and sacral nerve stimulation requests: include documentation of a screening/trial period for neuromodulation when applicable, objective improvement and functional impact, and operative/trial notes. For permanent implantation provide percent improvement after a screening trial and details of function/ADL impact.

For sacral nerve stimulation: percentage of pain/symptom reduction with trial and operative/trial notes.
For SI joint permanent implantation: percentage improvement from screening trial.
Document prior therapies tried, dates, durations, and reasons for discontinuation.

Documentation Required

Submit diagnostic imaging and photographs via external portal (no faxes)

All diagnostic imaging required for review must be submitted via the UnitedHealthcare external portal at www.uhcprovider.com/paan. Faxed images or photos will not be accepted. Label images and photos with the date taken and the applicable case number or the member's name and ID number.

Submission method: external portal (www.uhcprovider.com/paan) — faxes will not be accepted.
Imaging labeling: include date taken and case number or member name/ID on each image.
Photographs: high-quality color images only; label with date taken and case number/member name/ID.

Denial Risk

Incomplete documentation may trigger denial

Incomplete documentation may trigger requests for additional information, delay decision-making, or lead to denial. Provide complete records up front to avoid repeated requests.

UnitedHealthcare may request additional information; lack of timely response may result in denial.
Ensure all required elements listed in this section and the specific service subsection are included.

Documentation Required

Face-to-face encounter recency

Face-to-face encounter recency: when applicable for DME, HMV, mobility devices, and certain orthotics/lifts, include documentation of a face-to-face encounter with the prescribing practitioner within six months prior to the prescription (written order).

Document date of face-to-face encounter within six months of prescription when required.
Include treating practitioner name and date of encounter in the submitted records.

Documentation Required

Site of service documentation (outpatient hospital vs office)

Site of service justification: if requesting an outpatient hospital location for a procedure, include a full history and physical, patient weight and comorbidities, a documented surgical plan, and physician privileging information supporting the need for the hospital outpatient department.

Outpatient hospital requests: submit H&P including weight and comorbidities and physician privileging information.
If inpatient stay is requested, include documentation supporting inpatient site-of-care (e.g., bilateral surgery, inability to tolerate outpatient care).

Documentation Required

Imaging submission method and labeling

Imaging submission method and labeling: diagnostic images and photographs must be uploaded to the external portal. Do not fax. Every image must be clearly labeled with the date taken and an applicable case number or member name/ID.

Required submission: external portal www.uhcprovider.com/paan — no faxes accepted.
Label each image/photo with date taken and case number or member name/ID.

Documentation Required

Required medical record elements (examples)

Required medical record elements (examples): include history of present illness, focused physical exam, comorbidities, current medications, diagnostic test results, treatment plan, and documentation of prior therapies tried, including dates, durations, and reasons for discontinuation.

History and physical relevant to the requested service.
Focused physical exam and findings supporting the request.
Comorbid medical conditions and current medications.
Diagnostic testing results (labs, imaging reports) with dates.
Physician treatment plan and proposed procedures.

Documentation Required

General documentation checklist

General documentation checklist: submit relevant clinic notes, operative reports, procedure notes, diagnostic test and imaging reports, face-to-face encounter documentation when required, current prescriptions/orders, equipment quotes, vendor invoices (for prosthetics), and high-quality images where requested.

Physician office notes and specialty consults.
Operative and procedure reports when applicable.
All relevant recent imaging reports and, upon request, the original labeled images.
Current prescription/written order and equipment or vendor quote for devices.
Documentation of prior treatments/therapies including dates, duration, and reason for discontinuation.

Documentation Required

Photograph submission requirements

Photograph submission requirements: when photographs are requested, submit high-quality color images via the external portal only. Do not fax photographs. Each photo must be labeled with the date taken and the applicable case number or member name/ID. Include multiple views (e.g., frontal and lateral) when requested.

High-quality color photos only; label with date taken and case number or member name/ID.
Submit photos via external portal (www.uhcprovider.com/paan); faxes not accepted.
Include required views (e.g., frontal, lateral) and scales/measures when applicable.

Note

naviHealth admission documentation (IRF/LTAC)

naviHealth admission documentation: for IRF and LTAC admissions, include hospital face sheet, H&P, therapy evaluations, most recent therapy notes (within past 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 include recent therapy and physician notes within the specified windows.

Initial admission: hospital face sheet, H&P, therapy evaluations, recent therapy notes (24–48 hrs), recent physician note (within 24 hrs), orders/med list, post-procedure notes, nursing admission assessment.
Continuation: therapy evaluations within 48 hrs and most recent therapy/physician notes within 24–48/24 hrs respectively.

Documentation Required

Prosthetic device documentation

Prosthetic device documentation: include prosthetist notes with medical justification for each requested component, vendor coversheet and invoice listing HCPCS codes, make/model and pricing (including unlisted items), current prescription, and documentation of limb status (level, date, etiology). For socket or component replacement provide comparative limb measurements and what adjustments were tried.

Vendor coversheet and narrative describing request; vendor invoice with HCPCS codes and make/model.
Prosthetist notes with justification for each component and description of current prosthesis.
Documentation of residual limb status, measurements, and reasons for replacement.

Documentation Required

Sleep apnea documentation (oral appliance, surgery)

Sleep apnea documentation: include a current evaluation by a physician or APP, a written order for the device or procedure, results of sleep studies with AHI/REI/RDI values, and documentation of prior treatment trials (e.g., PAP) including dates, duration, and reason for discontinuation or intolerance.

Physician/APP evaluation and current written order for oral appliance or surgical intervention.
Sleep study results showing severity (AHI/REI/RDI) and dates.
Prior treatments tried/failed (e.g., PAP) with dates and reason for discontinuation.

Documentation Required

Vertebral augmentation documentation

Vertebral augmentation (vertebroplasty/kyphoplasty): include condition onset and duration, pain severity and functional impact on ADLs, comorbidities, prior treatments and dates, imaging reports with levels/pathology, and labeled diagnostic images when requested. Provide operative plan and consent discussions when applicable.

Onset and duration of symptoms and impact on activities of daily living.
Reports of all recent relevant imaging and labeled images upon request (date taken and case number/member ID).
Documentation of prior conservative therapies tried, dates, duration, and reason for discontinuation.

Documentation Required

Records and imaging required

Records and imaging required (comprehensive): include office and specialty notes, H&P, operative/procedure reports, consultation notes, all relevant imaging reports and labeled images, laboratory and pathology results, device prescriptions/orders, vendor quotes/invoices, therapy notes, and high-quality photos when applicable.

Office and specialty notes including history, exam, and treatment plan.
Operative and procedure reports, post-op notes.
All relevant imaging reports and labeled images uploaded to the portal.
Vendor quotes/invoices, device prescriptions, and therapy/rehab notes.

Documentation Required

Objective metrics and scales

Objective metrics and validated scales: include performance and functional measures where applicable (e.g., KPS, ECOG, NYHA, VCSS, VDS, PROMs, pain scales). When used to demonstrate failure of conservative therapy, provide at least two measurements showing change or lack of improvement.

Include relevant scores (KPS, ECOG, NYHA, VCSS, VDS, PROMs) when requested.
Provide serial measurements (at least two) to demonstrate progression or lack of improvement.

Documentation Required

Evidence of prior therapies required / Prior treatments documentation

Evidence of prior therapies and prior treatments documentation: for many services include documentation of conservative therapy trials, dates, durations, objective response, and reasons for discontinuation. Provide details for specific prior treatments (e.g., pharmacotherapy, physical therapy, bracing, wound care, prior devices) and whether prior therapies were contraindicated or not tolerated.

List all prior therapies tried, including start/end dates, duration, and reason for discontinuation.
Provide objective response to prior treatments when available (e.g., pain scores, functional measures).
For NPWT: document prior local wound care, dates of prior NPWT on same wound and response.

Documentation Required

NPWT prior therapy documentation

Negative Pressure Wound Therapy (NPWT) specific prior therapy documentation: include wound history, wound measurements and staging, prior local wound care details, dates of prior NPWT use on the same wound (if any) and clinical response, debridement dates, and that the wound is free of contraindications (exposed vasculature, active bleeding, malignancy in wound, etc.).

Wound stage, size, location, measurements, and type.
Date(s) of surgery and debridement and the date NPWT was started.
Documentation that favorable wound environment has been maintained and that contraindications are absent.
If NPWT previously used on same wound, include dates and favorable clinical response.

Malignancy or open fistulaPresence of malignancy in the wound or an open fistula to an organ/body cavity excludes NPWT

Uncontrolled infection or osteomyelitisUncontrolled soft tissue infection or osteomyelitis in the wound vicinity excludes NPWT