Effective Date: March 1, 2025

Medical Records Documentation Used for Reviews

This protocol lists medical records documentation used and which may be required, when applicable for reviews. This content is developed using the clinical
criteria in UnitedHealthcare medical policies in conjunction with the guidance provided by UnitedHealthcare physicians and pharmacists with experience in
reviewing service requests for coverage. This medical record documentation content was developed in an effort to decrease the need for repeated requests for
additional information and to improve turnaround time for coverage decisions.

We reserve the right to request more information, if necessary. Medical record documentation content used for case review(s) may vary among various
UnitedHealthcare Commercial, UnitedHealthcare Community Plan, and UnitedHealthcare Medicare Advantage benefit plans.

This content is provided for reference purposes only and may not include all services or codes. Listing of a service or code in this protocol does not imply that it is
a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws.

This protocol is the property of UnitedHealthcare and unauthorized copying, use or distribution of this information is strictly prohibited. It is regularly reviewed,
updated and subject to change.

Click a category from the Table of Contents to jump to the applicable section of this protocol.

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 1 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Table of Contents
Click a service category below to jump to the applicable section of this document.

Abnormal Uterine Bleeding and Uterine Fibroids ... 4
Airway Clearance Devices..................................... 4
Ambulance Service ‒ Non-Emergency Transport
(Ground or Air) ...................................................... 4
Apheresis.............................................................. 5
Bariatric Surgery ................................................... 5
Beds and Mattresses ............................................ 5
Breast Imaging for Screening and Diagnosing
Cancer .................................................................. 5
Breast Reconstruction ........................................... 6
Breast Reduction Surgery ..................................... 6
Brow Ptosis and Eyelid Repair .............................. 7
Cardiac Event Monitoring ...................................... 7
Carrier Testing Panels for Genetic Diseases ......... 7
Catheter Ablation for Atrial Fibrillation.................... 7
Cell-Free Fetal DNA Testing ................................. 8
Chromosome Microarray Testing (Non-Oncology
Conditions)............................................................ 8
Clinical Trials ........................................................ 8
Cochlear Implants ................................................. 8
Computed Tomographic Colonography ................. 8
Continuous Glucose Monitoring and Insulin Delivery
for Managing Diabetes .......................................... 8
Core Decompression for Avascular Necrosis ......... 9
Cosmetic & Reconstructive ................................... 9
Cosmetic & Reconstructive – Tissue Transfer (Flap)
Repair ................................................................. 10
Deep Brain and Cortical Stimulation .................... 10
Durable Medical Equipment, Orthotics, ................ 10
Medical Supplies, and Repairs/Replacements -
Ventilator ............................................................ 10
Durable Medical Equipment, Orthotics, Medical
Supplies, and Repairs/Replacements - Orthotics . 11
Electric Tumor Treatment Field Therapy .............. 11
Electrical and Ultrasound Bone Growth Stimulators
 ........................................................................... 11
Electrical Stimulation for the Treatment of Pain and
Muscle Rehabilitation - Functional Neuromuscular
Stimulation (FES) ................................................ 12
Electrical Stimulation for the Treatment of Pain and
Muscle Rehabilitation - Neuromuscular Electrical
Stimulators (NMES) ............................................ 12

Medical Records Documentation Used for Reviews
MRDUR01.05

Epidural Steroid Injections for Spinal Pain ........... 12
Facet Joint and Medial Branch Block Injections for
Spinal Pain ......................................................... 13
FDA Cleared or Approved Companion Diagnostic
Testing ................................................................ 13
Gastrointestinal Motility Disorders, Diagnosis and
Treatment ........................................................... 13
Gastrointestinal Pathogen Nucleic Acid Detection
Panel Testing for Infectious Diarrhea ................... 13
Gender Dysphoria ............................................... 14
Genetic Testing for Cardiac Disease ................... 14
Genetic Testing for Hereditary Cancer................. 14
Genetic Testing for Neuromuscular Disorders ..... 14
Gynecomastia Surgery ........................................ 14
Habilitation and Rehabilitation Therapy
(Occupational, Physical and Speech) – For
Community Plans ................................................ 15
Hearing Aids and Devices Including Wearable,
Bone-Anchored and Semi-Implantable ................ 18
Hysterectomy ...................................................... 18
Implanted Electrical Stimulator for the Spinal Cord
 ........................................................................... 18
Implanted Spinal Drug Delivery Systems ............. 19
Infertility Diagnosis, Treatment and Fertility
Preservation........................................................ 19
Injectables for Reconstructive Procedures ........... 19
Intensity Modulated Radiation Therapy (IMRT) .... 20
Interspinous Fusion and Decompression Devices 20
Light and Laser Therapy ..................................... 21
Liposuction for Lipedema .................................... 21
Lower Extremity Endovascular Procedures ......... 21
Lower Extremity Prosthetics ................................ 22
Magnetic Resonance Imaging (MRI) and Computed
Tomography (CT) Scan – Site of Service............. 22
Mechanical Stretching Devices............................ 22
Mobility Devices, Options and Accessories .......... 22
Molecular Oncology Testing for Hematologic
Cancer Diagnosis, Prognosis, and Treatment
Decisions ............................................................ 23
Molecular Oncology Testing for Solid Tumor Cancer
Diagnosis, Prognosis, and Treatment Decisions .. 24

naviHealth Admissions for Inpatient Rehabilitation
Facility (IRF) ....................................................... 24
naviHealth Admissions for Long Term Acute Care
(LTAC) ................................................................ 24
naviHealth Admissions for Skilled Nursing Facility
(SNF) .................................................................. 25
Negative Pressure Wound Therapy - Wound VAC
 ........................................................................... 25
Obstructive and Central Sleep Apnea Treatment -
Oral Appliances................................................... 26
Obstructive and Central Sleep Apnea Treatment -
Surgical............................................................... 26
Office Based Procedures Site of Service for
Commercial Plans ............................................... 26
Orthognathic (Jaw) Surgery................................. 26
Outpatient Surgical Procedures – Site of Service for
Commercial Plans ............................................... 27
Panniculectomy and Body Contouring Procedures
 ........................................................................... 27
Patient Lifts ......................................................... 28
Pectus Deformity Repair ..................................... 28
Percutaneous Neuroablation for Pancreatic Cancer
Pain, Severe Cancer Pain, and Trigeminal
Neuralgia ............................................................ 28
Percutaneous Patent Foramen Ovale (PFO)
Closure ............................................................... 28
Percutaneous Vertebroplasty and Kyphoplasty .... 29
Plagiocephaly and Craniosynostosis Treatment -
Cranial Orthotic ................................................... 29
Pneumatic Compression Devices ........................ 30
Preimplantation Genetic Testing and Related
Services .............................................................. 30
Private Duty Nursing ........................................... 30
Prostate Surgeries and Interventions ................... 31
Proton Beam Therapy ......................................... 32
Radiation Therapy: .............................................. 32
Fractionation, Image-Guidance, and Special
Services .............................................................. 32
Rhinoplasty and Other Nasal Surgeries ............... 33
Sacral Nerve Stimulation for Urinary and Fecal
Indications .......................................................... 33
Sacroiliac Joint Interventions ............................... 34

Page 2 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Screening Colonoscopy – Site of Service ............ 34
Seat Lifts............................................................. 34
Sinus Surgeries and Interventions ....................... 34
Sleep Studies ...................................................... 35
Speech Generating Devices ................................ 35
Spinal Fusion and Bone Healing Enhancement
Products ............................................................. 36
Spinal Fusion and Decompression ...................... 36
Stereotactic Body Radiation Therapy and
Stereotactic Radiosurgery ................................... 37
Surgery of the Ankle............................................ 37

Table of Contents
Click a service category below to jump to the applicable section of this document.
Surgery of the Elbow ........................................... 38
Surgery of the Foot ............................................. 39
Surgery of the Hand or Wrist ............................... 39
Surgery of the Hip ............................................... 40
Surgery of the Knee ............................................ 40
Surgery of the Shoulder ...................................... 41
Surgical and Ablative Procedures for Venous
Insufficiency and Varicose Veins ......................... 42
Sympathetic Blockade ......................................... 43
Total Artificial Disc Replacement for the Spine .... 43

Transarterial Radioembolization (TARE)/ Selective
Internal Radiation Therapy (SIRT) for the Treatment
of Malignant Cancers of the Liver ........................ 44
Transcatheter Heart Valve Procedures ................ 44
Treatment of Temporomandibular Joint Disorders 44
Upper Extremity Prosthetic Devices .................... 45
Vagus and External Trigeminal Nerve Stimulation 45
Video Electroencephalographic (VEEG) Monitoring
and Recording .................................................... 46
Whole Exome and Whole Genome Sequencing .. 46

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 3 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Abnormal Uterine
Bleeding and Uterine
Fibroids

Medical Records Used for Reviews
Medical notes documenting the following, when applicable:

  Condition requiring procedure
  Relevant physical exam
  Signs and symptoms, including uterine bleeding and possible impact on activities of daily living (ADLs)
  Co-morbid medical condition(s), including, when applicable:

  Presence or absence of anemia
  Presence or exclusion of thyroid diseases
  Presence or exclusion of bleeding disorder
  Exclusion of pregnancy
  Presence or absence of pelvic or abdominal pain or discomfort
  Presence or absence of urinary frequency or urgency
  Presence or absence of dyspareunia

  Reports of all recent imaging studies and applicable diagnostics, including:

  Results of cervical cytology
  Results of endometrial biopsy
  Results of hysteroscopy with dilatation and curettage (D & C)
  Uterine or fibroid (s) measurements by imaging within the last year
  Presence or absence of ureteral compression

  History of past relevant procedure(s)/ surgery (ies)
  Prior therapies/treatments tried, failed, or contraindicated; include the dates, duration, and reason for discontinuation

Airway Clearance
Devices

Ambulance Service ‒
Non-Emergency
Transport (Ground or Air)

Medical notes documenting the following, when applicable:

  Diagnosis
  Current prescription from physician
  Failed standard treatments to adequately mobilize retained secretions
  CT scan report confirming diagnosis of bronchiectasis if applicable
  Frequency of exacerbations requiring antibiotic therapy
  Duration and frequency of productive cough
  For continuation beyond the two-month trial, medical notes documenting

  Patient tolerance of the device
  Efficacy in using the device (member’s response to therapy)

Include the following:
  Date of Service
  Ordering physician’s name and phone#
  Physician including reason for requested transport method
  Any additional equipment or personnel needed for transport
  Member’s diagnosis and chief complaint
  Member’s current condition including:

  Co-morbidities
  Current functional limitations
  Description of members inpatient stay and progress if applicable

  Where member is traveling from including facility name, contact name and phone number
  Where member is traveling to including facility name, contact name and phone number

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 4 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Mileage for transport including air mileage and land mileage for transport

Apheresis

Bariatric Surgery

Medical notes documenting the following, when applicable:

  Medical history, including transfusion history
  Diagnosis
  Treatment plan

For initial bariatric surgery, provide medical notes documenting all of the following:

  Height
  Weight
  Current and five-year history of BMI (body mass index)
  Diet history
  Co-morbidities
  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

  For subsequent bariatric surgery, provide medical notes documenting all of the above in addition to the following:

  Previous unsuccessful medical treatment

Initial bariatric surgery performed and date and subsequent complications that require further surgical intervention

Beds and Mattresses

Medical notes documenting the following, when applicable:

  Current prescription (written order) from physician, including:

Initial, ongoing, or replacement request

  Rental or purchase
  Specific HCPCS code(s) for item and each accessory requested
  Equipment make, model and price quotation

If replacement, current device used, date of initial acquisition, status of warranty and reason for replacement

  Medical notes documenting the following, when applicable:

  Diagnosis and detail of member condition(s) or risk(s)
  Current transfer and bed mobility skills
  Current functional limitations with regards to activities of daily living
  Member weight and height
  Reason for positioning of the body not accommodated with a standard bed
  Ability to transfer from a fixed height bed with or without assistance
  Medical need for variable height bed
  Prior approaches tried, failed, or contraindicated; include the dates and reason for discontinuation

  Physician treatment plan
  For safety enclosures with beds in addition to the above, also include the following when appropriate:

  Evaluation for contraindications to use of the equipment
  Member assessment for physical, environmental, and behavioral factors
  Physician directed written monitoring plan

Provider should call the number on the member’s ID card when referring for radiology services.

Medical notes documenting the following, when applicable:

  Recent history and physical

Breast Imaging for
Screening and
Diagnosing Cancer

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 5 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Documentation to support medical necessity (i.e., family history, prior treatment, genetic testing results, other imaging

Breast Reconstruction

Breast Reduction
Surgery

studies and diagnostic results, etc.)

  Applicable CPT code

NOTE: These documentation requirements only apply when a Pre-Determination is requested. Mastectomy after a
diagnosis of breast cancer does not require Prior Authorization/Advance Notification.
Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Chief complaint, including history of the complaint
  Relevant medical and family history
  Relevant surgical history, including dates and whether the surgery is for removal, replacement (of an implant, specify

type, silicon or saline), or revision of a previous surgery

  Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested. Consultation with requesting surgeon may be of benefit to select the optimal images
NOTE: Diagnostic images must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

7.  Reports of all recent imaging studies and applicable diagnostics
8.  For CPT codes 19370 and 19371 require submission of high-quality color photograph(s)

NOTE:All photographs must be labeled with the:

  Date taken
  Applicable case number obtained at time of notification, or member’s name and ID number on the photograph(s)
Submission of color photographs can be submitted via the external portal at www.uhcprovider.com/paan; faxes of color
photos will not be accepted

9.  Complications which necessitate the need for removal of the prosthetic

NOTE: For capsular contracture include Baker grade and functional impairment

10.  Physicians plan of care, including estimated volume of breast tissue per breast to be removed
Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention, including:

  History of the chief complaint and associated symptoms
  Estimated risk of breast cancer

  Physical exam including member’s height and weight
  Reports of recent imaging studies and applicable diagnostic tests (within 1 year), including to rule out:

  Tumor or malignant changes of the breast
  Orthopedic, neurologic, rheumatologic, endocrine or metabolic condition

  Description of physiologic functional impairments (e.g., back pain, grooving from bras straps, skin breakdown,

paresthesias, etc.)

  For a diagnosis of macromastia, include high quality color photograph(s); all images must be labeled with the

  Date taken

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 6 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Brow Ptosis and Eyelid
Repair

  Applicable case number obtained at time of notification or member's name and ID number on the photograph(s)

NOTE: Submission of color image(s)are required and can be submitted via the external portal at
www.uhcprovider.com/paan; faxes will not be accepted

  Physicians plan of care, including estimated volume of breast tissue per breast to be removed

Medical notes documenting the following, when applicable:

  History of condition requiring treatment
  Visual complaints, including functional impairments that interfere with activities of daily living (ADL) and ruling out other

causes

  Eye exam including best corrected visual acuity in both eyes
  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation
  Recent diagnostic testing including:

  Peripheral or Superior Visual Fields automated, reliable, un-taped and taped including percent improvement or

number of degrees improvement

  Reason Visual Field testing is not feasible

  Marginal reflex distance (MRD-1)
  High-quality photograph(s); all photos must be:

  Full face, eye level, frontal and lateral with the member looking straight ahead, light reflex visible and centered
  Labeled with the date taken and the applicable case number obtained at time of notification, or member’s name

and ID number on the photograph(s)

NOTE: Submission of color photos can be submitted via the external portal at www.uhcprovider.com/paan; faxes of
color photographs will not be accepted

Cardiac Event Monitoring  Medical notes documenting the following, when applicable:

  Physician Order
  Pertinent diagnoses or symptoms
  Conditions putting the member at high risk for arrhythmias
  Result of non-invasive cardiac monitoring unless contraindicated, or non-diagnostic, to include duration of monitoring
  Test results supporting cardiac etiology (e.g. electrophysiological studies, Tilt Table testing, relevant imaging results,

Carrier Testing Panels
for Genetic Diseases

Catheter Ablation for
Atrial Fibrillation

etc.) unexplained symptoms, or unexplained syncopal episodes

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Family history relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing
  Any prior genetic testing results on affected individual in the family
  Genetic counseling (if available)

Medical notes documenting the following, when applicable:

  Diagnosis
  Recent physical exam
  Signs and symptoms including onset, duration, and frequency
  Reports of all recent imaging studies and applicable diagnostics
  Treatments tried, failed, or contraindicated. Include the dates, duration and reason for discontinuation
  Physician treatment plan

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 7 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Cell-Free Fetal DNA
Testing

Medical Records Used for Reviews
Medical office notes documenting the following, when applicable:

  Maternal age
  History of prior pregnancy with a trisomy, if applicable
  History of parental balanced Robertsonian translocation
  Abnormal first- or second-trimester screening test result
  Counseling provided by genetic counselor or prenatal provider on the risks and benefits of testing using Shared

Chromosome Microarray
Testing (Non-Oncology
Conditions)

Clinical Trials

Cochlear Implants

Decision Making

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Complete family history (usually three-generation pedigree) relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Any prior genetic testing results
  Genetic counseling (if available)

Provider should call the number on the member’s ID card when referring for any clinical trial.

Medical notes documenting the following, when applicable:

  Diagnoses and relevant medical history, including vaccination status or waiver
  Degree and frequencies of sensorineural hearing impairment on each side
  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation
  Physical exam and reports of recent relevant imaging studies, including:
  Presence or absence from middle ear infection or mastoid cavity
  An accessible cochlear lumen that is structurally suited to implantation
  Presence or absence of lesions in the auditory nerve and acoustic areas of the central nervous system
  Presence or absence of tympanic membrane perforation

  Other applicable diagnostic tests
  Member’s cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation
  Proposed procedure(s) including

  Type of cochlear implant or other auditory implant including the name of the device
  Whether this request is part of a staged procedure

Provider should call the number on the member’s ID card when referring for radiology services
Medical notes documenting the following, when applicable:

  Recent history and physical
  Co-morbid medical condition(s)
  Documentation to support medical necessity
  Applicable CPT code

Insulin Delivery
Medical notes documenting the following:

  Provide the member’s current type of diabetes (i.e. type I type II or Gestational)
  Member’s lab results and office notes from within the last three (3) months
  Treatment plan
  Current signed physician order
  Provide the type of make and model of the device requested

Computed Tomographic
Colonography

Continuous Glucose
Monitoring and Insulin
Delivery for Managing
Diabetes

Medical Records Documentation Used for Reviews
MRDUR01.05

CGM Initial Request

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Page 8 of 46
Effective 03/01/2025

Service

Medical Records Used for Reviews
Medical notes documenting the following:

  Provide the member’s current type of diabetes (i.e. type I type II or Gestational)
  Member’s lab results and office notes from within the last three (3) months
  Treatment plan
  Frequency and severity of hypoglycemic events, including glucose level
  Current signed physician order
  Provide the type of make and model of the device requested

Core Decompression for
Avascular Necrosis

Cosmetic &
Reconstructive

CGM Continued Use
Medical notes documenting the following:

  Provide the member’s current type of diabetes (i.e. type I type II or Gestational)
  Physician assessment and lab results within the last 6 months including adherence to the prescribed CGM regimen

and treatment plan

  Treatment plan
  Current signed physician order
  Provide the type of make and model of the device requested

Medical notes documenting the following, when applicable:

  Condition requiring procedure, including stage of avascular necrosis
  Signs and symptoms including onset, duration, and frequency
  Associated co-morbidities
  Results of all recent imaging and diagnostic tests, including:
Imaging reports (x-ray, CT, bone scan, MRI, etc.)

  Histology

  Treatments tried, failed or contraindicated, include dates, duration and reason for discontinuation
  Member’s degree of pain and functional disability
  Proposed procedure

Medical notes documenting the following, when applicable:

  History of medical conditions requiring treatment or surgical invention which includes all of the following:

  To prove medical necessity, a well-defined physical/physiologic abnormality resulting in a medical condition that

requires treatment

  Recurrent or persistent functional impairment caused by the abnormality

  Clinical studies/tests addressing the physical/physiologic abnormality confirming its presence and degree to which it

causes impairment

  High-quality color image(s) of the physical/physiologic abnormality:

NOTE: All image(s) must be labeled with the:

  Date taken and
  Applicable case number obtained at time of notification, or member’s name and ID number on the image(s)

Submission of color image(s) are required and can be submitted via the external portal at www.uhcprovider.com/paan;
faxes will not be accepted

  Physician plan of care with proposed procedures and whether this request is part of a staged procedure; indicate how

the procedure will improve and/or restore function

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 9 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Cosmetic &
Reconstructive – Tissue
Transfer (Flap) Repair

Medical Records Used for Reviews
Medical notes documenting the following, when applicable:

  History of medical conditions requiring treatment or surgical intervention, including:

  A well-defined physical/physiologic abnormality resulting in a medical condition that requires treatment
  Recurrent or persistent functional deficit caused by the abnormality

  Clinical studies/tests addressing the physical/physiologic abnormality confirming its presence and degree to which it

Deep Brain and Cortical
Stimulation

causes impairment

  Color photos, where applicable, of the physical and/or physiological abnormality
  Physician plan of care with proposed procedures including expected outcome

Medical notes documenting the following, when applicable:

  Diagnosis
  Specific procedure being requested
  History of the medical condition(s) requiring treatment or surgical intervention, including conditions interfering with

activities of daily living

  Documentation of signs and symptoms; including onset, duration, and frequency, including:seizures history and

number of seizures per month

  Physical exam
  Relevant medical history, including:

  Medical co-morbidities
  Psychiatric co-morbidities

  Treatments tried, failed, or contraindicated. Include the dates, duration, and reason for discontinuation
  Current medications used to treat condition, include start date
  Relevant surgical history, including previous movement disorder surgery and dates
  Reports of all recent imaging studies and applicable diagnostics, including:

  Results of imaging related to skeletal deformities and cervical myelopathy
  Results of brain MRI
  Results of video electroencephalographic (EEG) monitoring
  Results of levodopa challenge
  Results of Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

  Physician treatment plan, including:

  Member understanding of surgical risk, complications and need for follow-up
  Planned placement of electrodes for preoperative mapping

Medical notes documenting the following, when applicable:

  Current prescription from physician including ventilator settings and hours of use per day
  Face – to – face evaluation which includes

  Medical history and respiratory condition supporting the need for a ventilator versus CPAP or BIPAP
  Other therapies with settings trialed, failed or ruled out and clinical justification of failure

  Additional testing to support need for ventilator vs. CPAP or BiPAP

  ABGs
  PFTs
  Overnight Oximetry
  Sleep Study

  Physician Office Notes that include the following:

  Plan of Care to include the use as intermittent or continuous

Durable Medical
Equipment, Orthotics,
Medical Supplies, and
Repairs/Replacements -
Ventilator

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 10 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Durable Medical
Equipment, Orthotics,
Medical Supplies, and
Repairs/Replacements -
Orthotics

  Member compliance with the treatment plan

Prognosis
Medical notes documenting the following, when applicable:

  Current prescription from physician
  Provider office notes including:

  Diagnosis
  Physical exam related to support the need of the orthotic. Include the neurological, circulatory, skin and

musculoskeletal examination that supports the request

  Functional impairment that is interfering with activities of daily living (ADL’s)
  Date and type of injury/ surgery, if applicable

  Orthotist notes to include the following:

  Equipment quote with billing codes and cost
  Reason for the orthotic

If a replacement, provide age of current orthotic and reason for replacement

Electric Tumor Treatment
Field Therapy

Medical notes documenting the following, when applicable:
For treatment of newly diagnosis glioblastoma

  Physician Order
  Diagnosis
  Physician notes to include the following

  Documenting prior treatment with Radiation Therapy
  Provide results of the Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG)

Performance Status

  Documentation that the member has been counselled that the device must be worn at least 18 hours daily
  Documentation that member is only taking Temozolomide for cancer drug

For treatment of a reoccurrence of glioblastoma

  Physician Order
  Diagnosis
  Physician notes to include the following:

  Provide results of the Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG)

Performance Status

  Documentation that the member has been counselled that the device must be worn at least 18 hours daily

For continued therapy

  Date and results of the most recent MRI imaging prior to the request to continue therapy
  Documentation that member is taking Temozolomide as the only cancer drug
  Provide results of the Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group ECOG

Performance Status

  Documentation that the member has been wearing the device for at least 18 hours per day

Electrical and Ultrasound
Bone Growth Stimulators

Electrical and Bone Growth Stimulators (E0747, E0748 & E0749)
Medical notes documenting the following, when applicable:

  Current physician prescription or order
  Any risk factors that apply:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 11 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Member with co-morbid conditions such as diabetes, obesity, osteoporosis, or current tobacco use that could

compromise bone healing

  Spondylolisthesis (including grade)

If the member has had or will be having a spinal fusion, include the following:

Date of surgery, either past or future and number of vertebral levels fused; or
Documentation of failed spinal fusion and date of reoperation of same site

Ultrasonic Bone Growth Stimulators (E0760)
Medical notes documenting the following, when applicable:

  Current physician prescription or order
  Date, site and type of fracture
  Diagnostic imaging reports
  Treatment of the fracture, including treatment already completed (date of surgery(ies) if applicable) and treatment

planned

Medical notes documenting the following, when applicable:
  Date of spinal cord injury and/or restorative surgery
  Specific device to be implanted

Intact lower motor units (both muscle and peripheral nerve)

  Muscle and joint stability for weight bearing and the ability to support upright posture independently
  Muscle contractions and sensory perception response
  Transfer ability and independent standing tolerance
  Hand and finger dexterity
  Absence of hip and knee degenerative disease
  Absence of history of long bone fracture secondary to osteoporosis

  High level of motivation, commitment and cognitive ability for device use

Medical notes documenting the following, when applicable:

  Current prescription from physician
  Diagnoses for the condition(s) needing treatment
  Clinical notes including:

  History
  Physical exam
  Laboratory testing
  Physician treatment plan

For initial Injection medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Documentation of signs and symptoms; including onset, duration, and frequency
  Physical exam demonstrating presence of radicular pain
  Relevant medical history related to the spine or surrounding tissues
  Treatments tried (e.g. pharmacotherapy, exercises), failed, or contraindicated; include the dates, duration of treatment

and reason for discontinuation

  Relevant surgical history, including dates
  Reports of all recent imaging studies and applicable diagnostics

Electrical Stimulation for
the Treatment of Pain
and Muscle
Rehabilitation -
Functional
Neuromuscular
Stimulation (FES)

Electrical Stimulation for
the Treatment of Pain
and Muscle
Rehabilitation -
Neuromuscular Electrical
Stimulators (NMES)

Epidural Steroid
Injections for Spinal Pain

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 12 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Physician treatment plan, including:

Facet Joint and Medial
Branch Block Injections
for Spinal Pain

  Location of proposed injection (side and level)
  Plan for use of fluoroscopic, CT or ultrasound guidance

  For subsequent injection, in addition to the above, also include the following:

  Response to initial epidural injection, including

Duration of the effect
Percentage of pain reduction

For the initial injection provide medical notes documenting the following, when applicable:

  Diagnosis
  Documentation of history of the medical condition(s), signs and symptoms; include onset, duration, and frequency,

finding suggesting facet joint origin, severity of pain on a 1-10 scale after conservativie treatment (e.g.,
pharmacotherapy, exercises)

  Physical exam, including presence of findings on facet loading maneuvers
  Relevant medical and surgical history; including history of previous spinal procedures/interventions, including but not

limited to previous facet injection and previous surgery(ies)

  Treatments tried, failed, or contraindicated; include the dates, duration of treatment and reason for discontinuation
  Reports of all recent imaging studies and applicable diagnostics
  Physician treatment plan, including:

  Location of proposed injection (side and level)
  Plan for radiofrequency joint denervation/ablation procedure

  For second injection in addition to the above, also include the response to initial facet injection, including:

FDA Cleared or
Approved Companion
Diagnostic Testing

Gastrointestinal Motility
Disorders, Diagnosis and
Treatment

Gastrointestinal
Pathogen Nucleic Acid
Detection Panel Testing
for Infectious Diarrhea

  Level, side and date of initial and second injection
  Duration of the effect
  Description of functional improvement of physical functions

Medical notes documenting the following, when applicable:

  Cancer type and stage
  Results of prior comprehensive genomic profiling, if applicable
  Proposed treatment based on results of genetic testing (if available)

Medical notes documenting the following, when applicable:

  Diagnosis
  Relevant history to include symptomatology
  Physical findings
  Results of diagnostic tests and imaging studies
  Co-morbidities
  Medical treatments tried, failed and contraindicated
  Current physician treatment plan, if applicable

Medical notes documenting the following, when applicable:

  Current diagnosis
  History of illness and date of onset
  Co-morbidities
  Results of blood cultures and other lab tests
  Number of pathogen targets being tested
  Physician treatment plan based on the results of panel testing

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 13 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Gender Dysphoria

Medical Records Used for Reviews
Medical notes documenting the following, when applicable:

  The number of months member has completed continuous hormone therapy or reason for medical contraindication or

non-indication

  A written clinical assessment from a Qualified Healthcare Professional experienced in treating Gender Dysphoria, who

has independently assessed the individual. The assessment should include all of the following:

  Persistent, well-documented gender dysphoria
  The member is capable to make a fully informed decision and to consent for treatment
  Member’s age
  Results of psychosocial-behavioral evaluation including management of coexisting mental health condition

  Treatment plan that includes ongoing and follow-up care by a Qualified Healthcare Professional experienced in treating

Gender Dysphoria, and whether request is part of a staged procedure

  For voice modification surgery, in addition to the above, also include documentation of presurgical voice lessons

and/or therapy

  For genital surgery, in addition to the above, also include:

  Clinical written assessment from a second Qualified Healthcare Professional experienced in treating Gender

Dysphoria, who has independently assessed the individual

  Documentation the member has completed at least 12 months of successful continuous full-time real-life

Genetic Testing for
Cardiac Disease

Genetic Testing for
Hereditary Cancer

Genetic Testing for
Neuromuscular
Disorders

experience in identified gender

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Complete family history (usually three-generation pedigree) relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing
  Any prior genetic testing results
  How clinical management will be impacted based on results of genetic testing
  Genetic counseling (if available)

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Complete family history (usually three-generation pedigree) relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing
  Any prior genetic testing results
  How clinical management will be impacted based on results of genetic testing
  Genetic counseling (if available)

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Complete family history (usually three-generation pedigree) relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing
  Any prior genetic testing results
  How clinical management will be impacted based on results of genetic testing
  Genetic counseling (if available)

Gynecomastia Surgery

Medical notes documenting all of the following, when applicable:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 14 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Habilitation and
Rehabilitation Therapy
(Occupational, Physical
and Speech) – For
Community Plans

  History of the medical condition requiring treatment
  Relevant history of prescribed medication
  Screening for non-prescription and/or recreational drugs or substances (examples include, but are not limited to the
following: testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine and calcium channel
blockers)

  Severity of pain and details of functional or physiological impairment (s)
  Frontal and lateral high quality, color photographs of the torso including expected outcome

NOTE: All images must be labeled with the:

  Date taken
  Applicable case number obtained at time of notification, or member’s name and ID number

Submission of photographs can be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

  Treatment plan for proposed surgery
  Reports of all recent imaging studies and applicable diagnostic tests, including:

  Mammography
  Hormone testing (e.g., beta-human chorionic gonadotropin, estradiol, follicle-stimulating hormone, luteinizing

hormone, prolactin, testosterone)

  Liver enzymes
  Serum creatinine
  Thyroid function studies

For Community Plan members provide documentation as indicated in the UHC Community Plan Medical Policy for
Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)

Request for the initial therapy evaluation/ initial therapy visit: A provider (PCP) (MD, DO, PA, or NP) or appropriate
specialist referral for the speech, physical and occupational therapy evaluation must be on file prior to the completion of the
evaluation, unless this requirement is exempted by the state. The therapy evaluation report must include all of the
following:

  A statement of the member’s medical history; and
  A comparison prior level of function to current level of function, as applicable; and
  A description of the member’s functional impairment including its impact on their health, safety, and/or independence;

and

  A clear diagnosis including the appropriate ICD-10 code; and
  Reasonable prognosis, including the member’s potential for meaningful and significant progress; and
  Baseline objective measurements (current versions of Standardized Assessments), including a description of the

member’s current deficits and their severity level which include:

  Current Standardized Assessment scores, age equivalents, percentage of functional delay, criterion-referenced

scores and/or other objective information as appropriate for the member’s condition or impairment

  Standardized assessments administered must correspond to the delays identified and relate to the long- and short-

term goals

  Standardized assessments results will not be used as the sole determinant as to the medical necessity of the

requested initial therapy visit
If the member has a medical condition that prevents them from completing standardized assessment(s), alternative
could include:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 15 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

The therapist provides in-depth objective clinical information using task analysis to describe the member’s
deficit area(s) in lieu of standardized assessments
The therapist should include checklists, caregiver reports or interviews, and clinical observation

The initial authorization for therapy must also include a Plan of Care (POC). Providers must develop a member’s POC
based on the results of the evaluation. The POC must include all the following:

  Functional or physical impairment; and
  Short and long-term therapeutic goals and objectives:
  Treatment goals should be specific to the member’s diagnosed condition or functional or physical impairment
  Treatment goals must be functional, measurable, attainable and time based
  Treatment goals must relate to member-specific functional skills

and

  Treatment frequency, duration, and anticipated length of treatment session(s)

Re-evaluations must be completed at least once every twelve months or more frequently based on state regulatory
requirements to support the need for on-going services. Re-evaluations performed more often than once should only be
completed when the member experiences a significant change in Functional Level in their condition or functional status.
The documentation must be reflective of this change. Re-evaluations must include current Standardized Assessment
scores, percentage of functional delay, criterion referenced scores or other objective information as appropriate for the
member’s condition or impairment. The therapy re-evaluation report must include all of the following:

  Date of last therapy evaluation; and
  Number of therapy visits authorized, and number of therapy visits attended; and
  Compliance to home program; and
  Description of the member’s current deficits and their severity level documented using objective data; and
  Objective demonstration of the member’s progress towards each treatment goal:
  Using consistent and comparable methods to report progress on long- and short-term treatment goals established
  For all unmet goals, baseline and current function so that the member’s progress towards goals can be measured

and

  An updated statement of the prescribed treatment modalities and their recommended frequency/duration; and
  A brief prognosis with clearly established discharge criteria; and

  An updated individualized POC must include updated measurable, functional and time-based goals:

  The updated POC/progress summary must not be older than 90 days; and

If the majority of the long and short-term goals were not achieved, the plan of care must include a description of the
barriers or an explanation why the goal(s) needed to be modified or discontinued
and

  A revised POC that the treating therapist has not made a meaningful update to support the need for continued services
will not be accepted. In addition, the notation of the percentage accuracy towards the member’s goals alone is not
sufficient to establish a need for continued, Medically Necessary therapy

All treatment session notes must include:

  Date of treatment
  Specific treatment(s) provided that match the CPT code(s) billed
  Start and stop time in treatment

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 16 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  The individual’s response to treatment
  Skilled ongoing reassessment of the individual’s progress toward the goals
  All progress toward the goals in objective, measurable terms using consistent and comparable methods
  Any problems or changes to the POC
  Member or caregiver involvement in and feedback about home program activities
  Signature and date of the treating provider

For Group Therapy the documentation must include all of the following:

  Prescribing provider’s order for group therapy; and

Individualized treatment plan that includes frequency and duration of the prescribed group therapy and individualized
treatment goals; and

  Name and signature of licensed therapist providing supervision over the group therapy session; and
  Specific treatment techniques utilized during the group therapy session and how the techniques will restore function
  Start and stop times for each session; and
  Group therapy setting or location; and
  Number of clients in the group

For feeding and swallowing evaluations, all of the following must be submitted:

Interview/case history; and

  Medical/clinical records including the potential impact of medications, if any; and
  Physical examination; and
  Previous screening and assessments; and
  Collaboration with providers and other caregivers

  During assessment, therapist’s determine whether the member is an appropriate candidate for treatment and/or
management; this determination is based on findings that include medical stability, cognitive status, nutritional
status, and psychosocial, environmental, and behavioral factors
and

  Assessment must result in one or more of the following outcomes:

  Description of the characteristics of swallowing function, including any breakdowns in swallow physiology
  Diagnosis of a Swallowing Disorder
  Determination of the safest and most efficient route (oral vs. non-oral) of nutrition and hydration intake

Identification of the effectiveness of intervention and support

  Recommendations for intervention and support for oral, pharyngeal, and/or laryngeal disorders
  Prognosis for improvement and identification of other relevant factors, if appropriate

Discharge criteria includes but is not limited to all of the following (as applicable):

  Treatment goals and objectives have been met
  Functional abilities have become comparable to those of others of the same chronological age and gender
  The desired level of function that has been agreed to by the member and provider has been achieved
  The skill of a therapist or other licensed healthcare professional (within the scope of his/her licensure) is not required
  The member exhibits behavior that interferes with improvement or participation in treatment and efforts to address

these factors have not been successful

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 17 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

In some situations, the member, family, or designated guardian may choose not to participate in treatment, may
relocate, or may seek another provider if the therapeutic relationship is not satisfactory. Therefore, discharge is also
appropriate in the following situations, provided that the member/client, family, and/or guardian have been advised of
the likely outcomes of discontinuation:

  There is a request to be discharged or request continuation of services with another provider
  The individual is transferred or discharged to another location where ongoing service from the current provider is

not reasonably available; efforts should be made to ensure continuation of services in the new locale

  The member is unable to tolerate treatment because of a serious medical, psychological, or other condition

Medical notes documenting the following, when applicable:

  What is being requested bone anchored, semi-implantable, implantable, etc.
  Medical notes documenting all of the following:

a.  Describe the type of hearing loss (sensorineural vs. conductive or mixed)
b.  Severity and frequencies affected
c.  Whether or not member is a candidate for an air-conduction hearing aid

  For replacement of any components indicate date of initial purchase and the reason for replacement

Medical notes documenting the following, when applicable:

  Primary indication for the hysterectomy
  Physician office notes which includes the following:

  Complete history and physical exam including OB/GYN, surgical and co-morbid medical condition(s), including

Hearing Aids and
Devices Including
Wearable, Bone-
Anchored and Semi-
Implantable

Hysterectomy

thyroid disease

  Symptoms attributable to pelvic disease, including:

Duration
Severity
Relation to menstrual cycle
Impact on activities of daily living (ADL)
  Reports of relevant diagnostic evaluations, including:

Laboratory (including genetic testing results)
Pathology (including biopsy results)
Imaging includes Ultrasound, MRI, CT, etc.
Prior procedure/operative reports

Implanted Electrical
Stimulator for the Spinal
Cord

  Diagnostic procedures (e.g. endometrial sampling, PAP, laboratory studies, hysteroscopy or D&C)
  Reports of all treatments attempted, declined, contraindicated or failed or including dates and clinical response.

Medical notes documenting the following, when applicable:

Indicate if this request is for a trial or permanent placement; if for permanent placement, include:

  Percentage of pain reduction at least 50% pain relief with temporary implant
  Operative notes from the spinal cord stimulatory or dorsal root ganglion (DRG) trial

  Condition requiring procedure
  Physical examination
  Prior therapies/treatments tried, failed, or contraindicated; include the dates and reason for discontinuation
  Documentation of psychological evaluation
  Physician plan of care
  For revision or removal, include documentation, including:

  Details of complication

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 18 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews
  Complete treatment plan

Implanted Spinal Drug
Delivery Systems

Medical notes documenting the following, when applicable:

  Condition requiring procedure
  For cancer related pain:

  For trial:

Presence and location of metastatic lesions
Presence or absence of increased intracranial pressure
Life expectancy
Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation

  For implantation, in addition to the above also provide the degree of pain reduction after trial

  For spasticity:
  For trial

  Member’s symptoms, pain, location, and severity including functional impairment that is interfering with

activities of daily living (meals, walking, getting dressed, driving)
Results of Modified Ashworth Scale or Penn Spasm Frequency Scale
Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation
Psychiatric or substance use history
Presence or absence of increased intracranial pressure

  For implantation, in addition to the above also provide:
Degree of pain reduction after trial, if applicable
Score/ point reduction in the Modified Ashworth Scale or Penn Spasm Frequency Scale

  For chronic non-malignant pain:

  For trial:

Etiology of pain
Treatments tried, failed, contraindicated or refused. Include the dates and reason for discontinuation,
contraindication or refusal.
Documentation of consideration given to additional treatments for underlying conditions
Psychiatric or psychosocial issues/ history

  For implantation, in addition to the above also provide the degree of pain reduction after trial

Infertility Diagnosis,
Treatment and Fertility
Preservation

Injectables for
Reconstructive
Procedures

Medical notes documenting the following, when applicable:

Initial history and physical

  All clinical notes including rationale for proposed treatment plan
  All ovarian stimulation sheets for timed intercourse, IUI and/or IVF cycles
  All embryology reports
  All operative reports
  Laboratory report FSH, AMH, estradiol and any other pertinent information
  Ultrasound report antral follicle count and any other pertinent information
  HSG report
  Semen analysis

Medical notes documenting the following, when applicable:

  History of medical conditions requiring treatment or surgical intervention which includes all the following:

  To prove medical necessity, a well-defined physical/physiologic abnormality resulting in a medical condition that

requires treatment

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 19 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Intensity Modulated
Radiation Therapy (IMRT)

Interspinous Fusion and
Decompression Devices

  High-quality color photograph(s); all photographs must be labeled with:

  Date taken
  Applicable case number obtained at time of notification, or member’s name and ID number on the photograph(s)
Submission of color image(s) are required and can be submitted via the external portal at www.uhcprovider.com/paan;
faxes will not be accepted

Medical notes documenting the following, when applicable:
  Specific condition and target volume requiring IMRT
  Specific history of prior radiation therapy. Information to include sites of delivery, total dose and dose per fraction
  A statement documenting the special need for performing IMRT vs Conventional or 3-Dimensional radiation treatment.

If failure of dose constraints, cite the specific constraint, including protocol number, if applicable.

NOTE: only Quantec or RTOG dose constraints are applicable

  When applicable, for delivery of a prescribed radiation therapy course with IMRT, submit the dose prescription along
with documentation in the form of a clearly labeled, color comparative 3D and IMRT plans including dose volume
histogram and dose table, in absolute doses. When citing an RTOG dose constraint, provide the RTOG protocol
number

  An immediately adjacent area has been previously irradiated or will be irradiated, and abutting portals must be

established with high precision

For IMRT used for breast cancer, provide the above and answers to the following:

  Will the left-sided internal mammary nodes be treated?
  Will the patient be receiving partial breast irradiation (when dose is up to 5 fraction)?

For IMRT used for whole brain radiation, provide the above documentation in addition to the following:

  Presence or absence of brain metastasis
  Results of the Eastern Cooperative Oncology Group (ECOG) performance status or Karnofsky performance status

(KPS) status tests
  Prognosis time period
  Presence or absence of leptomeningeal disease

Medical notes documenting the following, when applicable:

  Condition requiring procedure including origin of the back pain
  Surgical history, including date(s) and outcome(s)
  Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Diagnostic image(s) report(s) by a radiologist, including presence or absence of:

  Degeneration of the disc
  Spondylolisthesis including Grade

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 20 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Light and Laser Therapy  Medical notes documenting the following, when applicable:

  History of medical conditions requiring treatment or surgical intervention which includes all the following:

  Describe the surgical technique(s) planned, including name of interspinous bony fusion device requested and use of an

interbody cage

  Specific location and size of the lesion
  To prove medical necessity, a well-defined physical/physiologic abnormality resulting in a medical condition that

requires treatment

  Recurrent or persistent functional impairment caused by the abnormality

  Treatments tried, failed, contraindicated or on-going; include the dates, duration, and reason for discontinuation
  Clinical studies/tests addressing the physical/physiologic abnormality confirming its presence and degree to which it

causes impairment

  High-quality color photograph(s); all photos must be labeled with the date taken and the applicable case number

obtained at time of notification, or member’s name and ID number on the photograph(s)

  Date taken
  Applicable case number obtained at time of notification, or member’s name and ID number on the photograph(s)
Submission of color image(s) are required and can be submitted via the external portal at www.uhcprovider.com/paan;
faxes will not be accepted

  Physician plan of care with proposed procedures and whether this request is part of a staged procedure. Indicate how

the procedure will improve and/or restore function
Medical notes documenting the following, when applicable:

  Diagnosis
  Specific procedure requested and treatment plan, including post-operative plan of care
  History of the medical condition(s) requiring treatment
  Level of functional impairment
  Physical exam including evidence of lipedema
  Upon request we may require high-quality color photographs.  All photographs must be labeled with:

  The date taken
  The applicable case number obtained at time of notification or member’s name and ID number on the

photograph(s)

NOTE: Submission of color photographs can be submitted via the external portal at www.uhcprovider.com/paan; faxes
of color photographs will not be accepted

  Relevant medical history
  Treatments tried, failed, or contraindicated. Include the dates, duration and reason for discontinuation
  Relevant surgical history, including dates

  Assessment of the cause of functional impairment by primary care provider or specialist in vascular conditions other
than treating surgeon

Medical notes documenting the following, when applicable:

  Diagnosis
  Relevant history and physical to include member symptoms and pertinent findings due ischemia
  Treatments tried, failed, and/or contraindicated, including structured exercise program, pharmacologic therapy, and

smoking cessation, if applicable

  Details of functional disability(ies) interfering with work or activities of daily living (ADL)
  Documentation of ischemic peripheral artery disease including Ankle-brachial index (ABI)

Liposuction for
Lipedema

Lower Extremity
Endovascular
Procedures

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 21 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Lower Extremity
Prosthetics

Magnetic Resonance
Imaging (MRI) and
Computed Tomography
(CT) Scan – Site of
Service

Mechanical Stretching
Devices

Mobility Devices, Options
and Accessories

  Diagnostic images (e.g., duplex ultrasound, computed tomography angiography , magnetic resonance

angiography , or invasive angiography) documenting the location and severity of occlusion

Medical notes documenting the following, when applicable:

  Vendor Coversheet with the narrative describing the request
  Vendor invoice listing the HCPCS codes, make model description, indicate if the item is right or left
  Other healthcare professional notes (i.e. physical therapist)
  Current prescription
  Physician office notes including documentation of:

  History related to the prosthetic request
  Examination findings to include strength, range of motion (ROM), condition of the contralateral limb, residual limb

length and shape, and skin integrity of residual limb

  Co-morbidities
  Specify absent limb, including the date, level and etiology of amputation
  Current Functional classification level include specific examples and expected rehab potential
  Describe limitations to activities of daily living (ADLs) include assistive devices to facilitate ambulation within and

outside the home

  Surfaces normally traversed include distance and environment
  Prosthetist notes to include medical justification for each of the requested prosthetic components

  Specify if the request is for initial prosthetic, preparatory prosthetic, definitive prosthetic, replacement of the entire
prosthetic leg, replacement of the prosthetic components/ accessories, or request for additional components and
accessories

  For replacement prosthesis, also include:

  The age of the current prosthesis and reason for replacement
  The components on the current prosthesis including socket, knee, foot, ankle, sock ply and liner thickness
  Describe changes in limb including, but not limited to, comparative residual limb measurements

  For socket replacement also describe what adjustments have been tried and failed

Provider should call the number on the member’s ID card when referring for radiology services.

If the location being requested is an outpatient hospital provide medical notes
documenting the following, when applicable:

  Recent history
  Physical examination including patient weight
  Patient condition, allergy, chronic disease and surgical plan
  Other specific criteria (see coverage rationale) that qualifies the individual for the site of service requested

Medical notes documenting the following, when applicable:

  Current prescription from physician
  Physician office notes that indicate all of the following:

  The affected joint
  The date of injury/ surgery
  Previous treatments attempted
  Treatment plan, including proposed duration of use
Medical notes documenting the following, when applicable:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 22 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Documentation of face-to-face encounter, within six months prior to the prescription (written order), from the treating

practitioner including date, when applicable

  Current prescription (written order) from physician, including:

Initial or replacement

  Rental or purchase
  Specific HCPCS code(s) for item and each accessory requested
  Equipment make, model and price quotation
  Rationale for selection of specific device and accessories

If repair or replacement, current device used, date of initial acquisition, status of warranty, as well as:

Proper use and continued benefit
Date the member acquired the original equipment and original payer
  Make, model, configuration and serial number of the existing equipment

Reason for repair or replacement
Detailed equipment replacement/ repair quote
History of previous repairs
Replacement cost
If stolen, include police report

  Diagnosis
  Most recent member weight and height
  For Wheelchairs and Power Mobility Devices - In addition to the above, provide medical notes documenting the

following, when applicable:

  Current ambulation status
  Transfer status
  Functional limitations as related to activities of daily living (ADLs) and mobility activities of daily living (MRADLs) as

well as risk of performing ADL

  Estimated duration of use
  Measurement of:

Strength
Ability to move and distance moved with assistive equipment
Coordination deficits
Pain level

  Primary setting of wheelchair/power mobility device
  Current mobility assistance devices
  Prior device(s) tried, failed or contraindicated. Include the dates, duration of use and reason for discontinuation
  Home and safety evaluation assessment

  For Wheelchair, Seating, Options and Accessories - In addition to the above, provide medical notes documenting

the following, when applicable

  Safe utilization, tolerance and benefit of requested device
  Proper use and continued benefit
  Prior accessories/ options tried, failed, or contraindicated. Include the dates and reason for discontinuation

Molecular Oncology
Testing for Hematologic
Cancer Diagnosis,

Medical notes documenting the following, when applicable:

  Confirmed or suspected hematologic cancer type and stage, if available, date of diagnosis
  Results of other diagnostic testing (e.g., blood smear, flow cytometry, FISH), if applicable

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 23 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Prognosis, and
Treatment Decisions
Molecular Oncology
Testing for Solid Tumor
Cancer Diagnosis,
Prognosis, and
Treatment Decisions

naviHealth Admissions
for Inpatient
Rehabilitation Facility
(IRF)

naviHealth Admissions
for Long Term Acute
Care (LTAC)

Medical Records Used for Reviews

  Proposed treatment based on results of genetic testing (if available)

Medical notes documenting the following, when applicable:

  Cancer type and stage including, if applicable, tumor size and nodal status
  Results of other biomarker testing (e.g., estrogen receptor, HER-2 neu), if applicable
  Proposed treatment based on results of genetic testing (if available)

Initial Admission:
Medical notes documenting the following, when applicable:

  Hospital Face Sheet
  History & Physical Document
  Therapy Evaluations
  Most Recent Therapy Notes (Within the Past 24-48 hours)
  Most Recent Physician Note (Within the Past 24 hours)
  Physician Orders Sheet/Medication List
  Post-Procedure Notes
  Nursing Admission Assessment

Continuation of Stay:
Medical notes documenting the following, when applicable:

  Therapy Evaluations (within the past 48 hours)
  Most Recent Therapy Notes (within the past 24-48 hours)
  Most Recent Physician Notes (within past 24 hours)
  Most Recent Nursing Notes (within past 24 hours)

Initial Admission:
Medical notes documenting the following, when applicable:

  Hospital Face Sheet
  History & Physical Document
  Therapy Evaluations
  Most Recent Therapy Notes (Within the Past 24-48 hours)
  Most Recent Physician Note (Within the Past 24 hours)
  Physician Orders Sheet/Medication List
  Post-Procedure Notes
  Nursing Admission Assessment

Continuation of Stay:
Medical notes documenting the following, when applicable:

  Therapy Evaluations (within the past 48 hours)
  Most Recent Therapy Notes (within the past 24-48 hours)
  Most Recent Physician Notes (within past 24 hours)
  Most Recent Nursing Notes (within past 24 hours)

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 24 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
naviHealth Admissions
for Skilled Nursing
Facility (SNF)

Negative Pressure
Wound Therapy - Wound
VAC

Medical Records Used for Reviews
Initial Admission:
Medical notes documenting the following, when applicable:

  Hospital Face Sheet
  History & Physical Document
  Therapy Evaluations
  Most Recent Therapy Notes (Within the Past 24-48 hours)
  Most Recent Physician Note (Within the Past 24 hours)
  Physician Orders Sheet/Medication List
  Post-Procedure Notes
  Nursing Admission Assessment

Continuation of Stay:

  Medical notes documenting the following, when applicable:
  Therapy Evaluations (within the past 48 hours)
  Most Recent Therapy Notes (within the past 24-48 hours)
  Most Recent Physician Notes (within past 24 hours)
  Most Recent Nursing Notes (within past 24 hours)

Medical notes documenting the following, when applicable:

  Diagnosis requiring Negative Pressure Wound Therapy (NPWT)
  History of the medical condition(s) requiring treatment
  Recent physical exam
  Signs and symptoms
  Treatments tried, failed, or contraindicated; include the dates, duration of treatment and reason for discontinuation
  Wound stage/ size/ location/ measurements
  Wound type (post-surgical, venous stasis, decubitus ulcer, diabetic neuropathic ulcer)
  Date(s) of surgery including debridement
  The date the NPWT (wound vacuum assisted closure (VAC)) was started

  Favorable wound environment has been maintained with:

  Appropriate dressing/ dressing changes
  Adequate nutritional status
  Management of incontinence, if applicable
  Wound is free of the following:

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 the vicinity of the wound

Uncontrolled soft tissue infection or osteomyelitis within vicinity of wound

  If member is diabetic, the member is maintained on a diabetic management program
  Member is turned and repositioned with the presence of a Stage III or IV pressure ulcer
  If applicable, indicate when NPWT (wound VAC) has been used previously on the same type of wound with a favorable
clinical response

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 25 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Obstructive and Central
Sleep Apnea Treatment -
Oral Appliances

Medical Records Used for Reviews
Medical notes documenting the following, when applicable:

  Diagnosis
  Documentation of most recent face-to-face evaluation with prescribing qualified physician (MD or DO), trained in sleep

medicine or an advanced practice provider (APP) under the direct supervision of a sleep medicine physician

  Current written order from physician, including:

Initial appliance or replacement
If replacement, current device used and reason for replacement

  Results of sleep study including severity of the OSA (AHI, REI, or RDI values, etc.)
  Prior treatments tried, failed, or contraindicated, including documentation of the member’s intolerance or refusal of
PAP, include the dates, duration of treatment and reason for discontinuation, including if positive airway pressure
(PAP) resulted in no therapeutic efficacy or patient refusal or intolerance
If the oral appliance is being prescribed for reasons other than OSA, an explanation of why appliance is needed

Medical notes documenting the following, when applicable:

  Diagnosis
  Specific procedure being requested
  History of the medical condition(s) requiring treatment or surgical intervention
  Reports of recent applicable imaging studies and diagnostic tests (e.g., Epworth Sleepiness Scale)
  Results of sleep study confirming diagnosis and severity of the OSA
  Treatments tried, failed, or contraindicated; include the dates, duration of treatment, and reason for discontinuation,
also include if positive airway pressure (PAP) resulted in no therapeutic efficacy or patient refusal or intolerance
In addition to the requirements above, medical notes documenting the following, when applicable for:

  For Mandibular Osteotomy, presence or absence of retrolingual or lower pharyngeal functional obstruction
  For Maxillomandibular Osteotomy and Advancement (MMA): presence or absence of craniofacial disproportion or

deformities, with evidence of maxillomandibular deficiency

  For Implantable Hypoglossal Nerve Stimulation (adult):

Body Mass Index (BMI)
Presence or absence of complete concentric collapse at the soft palate level
Percentage of central or mixed sleep apnea

Implantable hypoglossal nerve stimulation (adolescent age 10-18 years with Down Syndrome):

Surgical history or contraindication for adenotonsillectomy
Presence or absence of tracheostomy
Presence or absence of complete concentric collapse at the soft palate level confirmed by a medication
induced sleep endoscopy test
Refusal of an MMA procedure for non-concentric palatal collapse

If the location being requested is anything other than the office, provide medical notes documenting the following, when
applicable:
  History
  Physical examination including patient weight and co-morbidities
  Surgical plan
  Physician privileging information related to the need for the use of the hospital outpatient department
  American Society of Anesthesiologists (ASA) score, as applicable

Obstructive and Central
Sleep Apnea Treatment -
Surgical

Office Based Procedures
Site of Service for
Commercial Plans

Orthognathic (Jaw)
Surgery

Medical notes documenting the following, when applicable:

  Condition requiring procedure

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 26 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Comprehensive history of the medical condition(s) requiring treatment or surgical intervention; including:

  A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal

impairments) resulting in a medical condition that has required or requires treatment; and

  The physical and/or physiological abnormality has resulted in a functional deficit; and
  The functional deficit is recurrent or persistent in nature

  Reports of all recent imaging studies and applicable diagnostic tests, including:

  Cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its
presence and the degree to which it is causing impairment, with appropriate measurements, when applicable

  Radiologic image interpretations including lateral cephalometric radiograph, AP radiograph and panoramic

radiograph

  All related, supporting imaging (color photographs, radiologic images including lateral cephalometric radiograph, AP

radiograph, and panoramic radiograph) must be diagnostic quality
NOTE: All images must be labeled with the:

  Date taken
  Applicable case number obtained at time of notification, or member’s name and ID number

Submission of images can be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

  Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for

the improvement of the functional deficit

If the location being requested is an outpatient hospital provide medical notes documenting the following, when applicable:

  History
  Physical examination including patient weight and co-morbidities
  Surgical plan
  Physician privileging information related to the need for the use of the hospital outpatient department
  American Society of Anesthesiologists (ASA) score, as applicable
  Specific criteria (see coverage rationale) that qualifies the individual for the site of service requested

Medical notes documenting the following, when applicable:

  Primary complaint, history of complaint, and physical exam, including:

  Grade of panniculus
  Body mass index (BMI)
  History of recent weight loss in lbs/kgs
  History of weight stability and duration
  History of dermatologic complications

  Diagnosis of dermatologic complications (e.g., skin infection, ulcers, maceration, skin breakdown, etc.)
  Treatments (e.g., antibiotic, corticosteroid, antifungal) for dermatologic complications tried, failed, or contraindicated;

include the dates, duration of treatment, and reason for discontinuation

  Details of functional limitations due to pannus interfering with activities of daily living (ADL)
  Relevant surgical history, including dates
  Physician treatment plan, including specific and associated procedures
  Upon request we may require high-quality color photographs

  For panniculectomy, photographs of a full-frontal view of the hanging pannus, a full-frontal view of pannus elevated

that allows for the evaluation of any skin damage, and a full lateral view of the hanging pannus

Outpatient Surgical
Procedures – Site of
Service for Commercial
Plans

Panniculectomy and
Body Contouring
Procedures

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 27 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  All photographs must be labeled with the date taken and the applicable case number obtained at time of

notification, or member’s name and ID number on the photograph(s)

NOTE: Submission of color photographs can be submitted via the external portal at www.uhcprovider.com/paan; faxes
of color photographs will not be accepted

Patient Lifts

Medical notes documenting the following, when applicable:

  Documentation of most recent face-to-face encounter with prescribing physician, when applicable
  Current prescription (written order) from physician, when applicable including:

Initial or replacement

  Rental or purchase
  Specific HCPCS code(s) for item and each accessory requested
  Equipment make, model and price quotation

If replacement, current device used, date of initial acquisition, status of warranty and reason for replacement

  Medical notes documenting the following, when applicable:

  Diagnosis
  Member’s weight

Inability to safely make transfers between bed and a chair, wheelchair, or commode without the use of a lift

  Requirement for supine positioning
  Proper use and continued benefit

Pectus Deformity Repair   Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Documentation of functional limitation/impairment
  Results of all recent imaging studies and applicable diagnostics, including results of:

  CT scan including Haller Index or Correction Index calculation
  Pulmonary function test – total lung capacity
  Echocardiogram including ejection fraction
  Exercise stress test including cardiopulmonary function values

Percutaneous
Neuroablation for
Pancreatic Cancer Pain,
Severe Cancer Pain, and
Trigeminal Neuralgia

Percutaneous Patent
Foramen Ovale (PFO)
Closure

  Treatments tried, failed, or contraindicated. Include the dates, duration of treatment and reason for discontinuation
  Physician treatment plan

Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Documentation of signs and symptoms; including onset, duration, and frequency
  Physical exam
  Relevant medical history
  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation

Medical notes documenting the following, when applicable:

  History and co-morbid medical condition(s)
  Documentation of member’s symptoms
  Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays)
  Results of diagnostic testing performed to rule out other causes including, but not limited to, carotid disease,

hypercoagulable states or atrial fibrillation; and

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 28 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Documentation of an evaluation by a cardiologist and a neurologist and both are in agreement that the stroke is likely

Percutaneous
Vertebroplasty and
Kyphoplasty

embolic in nature

Medical notes documenting the following, when applicable:

  Onset of the condition, length and duration
  Documentation of member’s symptoms, pain, location, and severity including functional impairment that is interfering

with activities of daily living (meals, walking, getting dressed, driving)

  History and co-morbid medical condition(s)
  No evidence of spinal cord compression
  Treatments tried and failed
  Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and/or bone scan)
  Upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request, diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted.

Plagiocephaly and
Craniosynostosis
Treatment - Cranial
Orthotic

Medical notes documenting the following, when applicable:

  Current prescription from physician
  Diagnosis and indication(s) for cranial orthosis
  General physical exam related to support the need of the orthotic; include the neurological, circulatory, skin and

musculoskeletal examination that supports the request, as well as presence or absence of torticollis

  At least one of the following:

  Cranial vault asymmetry index (CVAI)
  Cephalic index (CI)
  Transcranial diameter difference (TDD)
  Cranial vault asymmetry (CVA)
  Children’s Healthcare of Atlanta (CHOA) level

For more details about the definition of these measurements, see InterQual criteria informational notes

  Documentation of treatments tried, failed, contraindicated. Include the dates, duration, and reason for discontinuation,

including:

  Repositioning
  Physical or occupational therapy
  Orthotist notes to include the following:

  Equipment quote with billing codes and cost
  Reason for the orthotic
  Anthropometric Measurements

  Date of planned or completed craniosynotosis surgery, if applicable
  Physician treatment plan, including:

  Plan to treat torticollis with cranial orthosis

In addition to the above, also provide the following for a request for continuation of treatment with a new cranial
orthotic:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 29 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Pneumatic Compression
Devices

Medical Records Used for Reviews
  Age of current orthotic
  Reason for replacement
  Adjustments/modifications to current cranial helmet if applicable
  Compliance with wear

Medical notes documenting the following, when applicable:

  Current prescription (written order) from physician, including:

Initial or replacement

  Rental or purchase
  Specific HCPCS code(s) for item and each accessory requested
  Equipment make, model and price quotation
  Why the features of the device are needed

If replacement, current device used, date of initial acquisition, status of warranty and reason for replacement

  Medical notes documenting the following, when applicable:

  Member diagnosis
  Member symptoms
  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation
  Treatment plan including:

Pressure in each chamber
Frequency
Duration of each treatment

Preimplantation Genetic
Testing and Related
Services

For Preimplantation Genetic Testing medical notes documenting the following, when applicable:

  Family history information related to the condition for which the member is being tested
  Genetic testing results supporting the family history concerns 

  Genetic counseling documentation (if available)

For Related Services medical notes documenting the following, when applicable:

Initial history and physical

  All clinical notes including rationale for proposed treatment plan
  All ovarian stimulation sheets for timed intercourse, IUI, and/or IVF cycles
  All embryology reports
  All operative reports
  Laboratory report FSH, AMH, estradiol, and any other pertinent information
  Ultrasound report antral follicle count and any other pertinent information
  HSG report
  Semen analysis

Medical notes documenting the following, when applicable

  Home Health Certification (CMS-485) which includes the Plan of Care signed by a physician (M.D. or D.O.) or signed

by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation

  Provide the clinical assessment including the days and hours of private duty nursing that is being requested (e.g.: 8

hours a day x 5 days a week (9 am – 5 pm))

  Details if the request is being made post-inpatient facility discharge
  Provide details of the caregiver(s) status including:

Private Duty Nursing

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 30 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews
  Willingness to participate
  Availability including:

Hours in the home

  Work schedule(s), including days and hours worked per day

Ability to learn and provide care

  Consultation notes if the member is receiving services from subspecialist
  Complete Medication Administration Record
  Physician-ordered clinical assessment(s) including need and frequency for related services:

  Tracheostomy and status of airway issues
  Respiratory support, including:

  Oxygen therapy

Noninvasive positive pressure ventilation (NIPPV)

  Mechanical ventilator status including documentation of weaning, if applicable

Need for nasal or oral suctioning
Nebulizer treatments
High-frequency chest wall oscillation (HFCWO)
Chest Therapy

  Blood draws
  Feeding
  Elimination
  Seizure activity, frequency and applicable interventions needed
  Wound care including type of wound, type of dressing and frequency of dressing changes
  Assistance with Activities of Daily Living (ADLs)
  Use of a mobility device
  Ability to transfer
  Use of cast, splint, brace or assistance with passive range of motion
  Communication limitations

Prostate Surgeries and
Interventions

  Behavioral issues
  Cognitive or sensory impairment issues

Medical notes documenting the following, when applicable:

  Diagnosis, including:

  Cancer risk group, including stage of disease
  Life expectancy
  Results of diagnostic prostate biopsy

  History of the medical condition(s) requiring treatment or surgical intervention, including dates
  Documentation of signs and symptoms; including onset, duration, and frequency
  Physical exam, including result of digital rectal exam
  Relevant medical history, including:

  List of current patient medication
  History of hematuria
  History of urinary incontinence
  Current urinary tract infection
  Allergy to nickel

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 31 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Treatments tried, failed, or contraindicated; include the dates, duration and reason for discontinuation
  Relevant surgical history, including dates
  Reports of all recent imaging studies and applicable diagnostics including:
  Results of uroflow test (Q-max and postvoid residual (PVR) test)
  Results of urinalysis
  Results of PSA test
  Results of prostate biopsies
  Results of prostate volume via transrectal ultrasound (TRUS)
  Prostate volume
  Presence of signs or symptoms of obstruction
  Presence of protruding median lobe of the prostate

  Physician treatment plan/surgical plan, including plans for pelvic lymph node dissection and radiotherapy

Proton Beam Therapy

Medical notes documenting the following, when applicable:

  History of medical condition requiring treatment
  Documentation that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy

techniques

  Evaluation includes a comparison of Definitive Therapy plans for PBT, IMRT, and stereotactic body radiation therapy

(SBRT)

  For hypofractionated radiation, provide the prescribed total dose and dose per fraction
  For delivery of radiation therapy course with standard fractionation, provide the dose prescription along with

documentation in the form of a clearly labeled, color comparative proton, and IMRT dose volume histogram and dose
table, in absolute doses noting that sparing of the surrounding normal tissue cannot be achieved with IMRT techniques

  Note: If citing an RTOG dose constraint, provide the RTOG protocol number
  Physician’s treatment plan

NOTE: The color comparative proton and IMRT dose volume histogram and dose table images can be submitted via
the external portal at http://www.uhcprovider.com/paan; faxes of images will not be accepted.

Radiation Therapy:
Fractionation, Image-
Guidance, and Special
Services

Radiation Therapy Fractionation
Medical notes documenting the following, when applicable:

  Radiation Oncologist notes
  Diagnosis and stage
  History of present illness and conditions
  History of prior surgical treatment
  Prior irradiated areas and their prescriptions
  Proposed treatment plan, including radiation prescription:

  Number of fractions
  Dose per fraction
  Total dose

Image-guided Radiation Therapy (IGRT)
Medical notes documenting the following, when applicable:

  Radiation Oncologist notes
  Diagnosis and stage
  History of present illness and conditions

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 32 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Current and previous treatments such as:

Rhinoplasty and Other
Nasal Surgeries

  Will you be radiating a previously irradiated area or an area directly adjacent to a previously irradiated area?
  Will IGRT be used in conjunction with another radiation therapy modality?
  Treatment modality

 History of prior surgical treatment

  Patient BMI
  Comparison plans, dose-volume histogram, clinical target volume margins, target motion documented by imaging
  Proposed treatment plan

Medical notes documenting the following, when applicable:

  Diagnosis
  Detailed history of nasal symptoms including evaluation and management notes for the date of service and the note for

the day the decision to perform surgery was made

  Evidence of chronic sinusitis with treatment, response, and duration
  History of treatments tried, failed, or contraindicated
  Specific diagnostic image(s) that show the abnormality for which surgery is being requested. Consultation with

requesting surgeon may be of benefit to select the optimal images
NOTE: Diagnostic images must be labeled with:

  The date taken and
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Submission of diagnostic image(s) is required via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

  Diagnostic imaging report(s)
  Details of functional impairment, if applicable
  Physician’s plan of care
  High-quality color image(s) (full face photos in cases of post-traumatic nasal deformity)

NOTE: All image(s) must be labeled with the:

  Date taken and
  Applicable case number obtained at time of notification, and member’s name and ID number on the image(s)

Submission of color image(s) is required via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted
  In addition to the above, additional documentation requirements may apply for CPT code 30560; refer to the Coverage
Determination Guideline titled Cosmetic and Reconstructive Procedures

Sacral Nerve Stimulation
for Urinary and Fecal
Indications

Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment, including:

  Origin of the dysfunction
  Presence or absence of bladder outlet obstruction
  Presence or absence of constipation

  Signs and symptoms
  Treatments tried, failed, or contraindicated; include the dates, duration of treatment and reason for discontinuation
  Bladder capacity in milliliters

Individual’s capacity to operate device

  For permanent implantation, include percentage improvement of symptoms in response to a screening trial

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 33 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service
Sacroiliac Joint
Interventions

Medical Records Used for Reviews
Medical notes documenting the following, when applicable:

  Condition requiring procedure
  History and co-morbid medical condition(s), including presence or absence of somatoform disorder or generalized pain

disorders

  Member’s symptoms including pain, location, severity and interference with activities of daily living (ADLs)
  Physical exam, including:

  Specific location of tenderness
  Presence or absence of acute neurological deficits
  Results of at least three tests:

Compression test
Distraction test
Patrick’s or FABER test

  Gaenslen’s test

Thigh thrust test
Sacral thrust test
Posterior provocation test

Screening Colonoscopy
– Site of Service

Seat Lifts

Sinus Surgeries and
Interventions

  Reports of all recent imaging studies and applicable diagnostics
  Treatments tried, failed, or contraindicated; include the dates, duration and reason for discontinuation
  Results of the fluoroscopically guided diagnostic intra-articular SIJ block(s) using local anesthetic (percent of pain

reduction)

If the location being requested is an outpatient hospital, provide medical notes documenting of the following:

  History relevant to procedure
  Co-morbidities necessitating outpatient hospital setting
  Physical examination, including patient weight
  Planned procedure

Medical notes documenting the following, when applicable:

  Current prescription from physician
  Physician office notes with clinical information documenting:

  Diagnosis
  Whether the member is completely incapable of standing up from a regular armchair or any chair in his/ her home
  Whether the member has the ability to ambulate once standing
  Whether all appropriate therapeutic modalities to enable the member to transfer from a chair to a standing position

(e.g., medication, physical therapy) have been tried and failed

  Make, model, and type of lift
  Price quote

Medical notes documenting the following, when applicable:

  Diagnosis
  History of illness
  Recent physical exam
  Signs and symptoms
  Treatments tried, failed, or contraindicated; include the dates and reason for discontinuation (e.g. intranasal

corticosteroids, antibiotic therapy, nasal lavage/irrigation)

  Recent CT scan report including the date of scan, documenting the following:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 34 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Which sinus has the disease, including side
  The extent of disease including the percent of opacification or the use of a scale such as the Modified Lund-

Mackay Scoring System

  Whether the images were taken pre- or post-medical management

  Upon request, recent CT scan images:

  That show the abnormality for which surgery is being requested
  Are the optimal images to show the abnormality of the affected area including, when applicable the use of a scale

such as the Modified Lund-Mackay Scoring System to define the severity

  Labeled with the date taken and the applicable case number obtained at time of notification, or member's name

and ID number
NOTE: CT images can be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

In addition to the above, for balloon sinus ostial dilation to treat Chronic Rhinosinusitis also include for which specific
sinus (es) the intervention is planned

Sleep Studies

Medical notes documenting the following, when applicable:

  Diagnosis or suspected diagnosis
  Physical exam including the member height, weight and BMI
  Clinical signs and symptoms
  Co-morbid conditions including pulmonary, cardiac, neuromuscular disease/neurodegenerative, neurologic
  History of chronic (>3 months) opiate use including frequency, dose and duration
  Reports of all recent imaging studies and applicable diagnostics, including when applicable:

  Previous sleep study (ies) include type and date
  Epworth Sleepiness score
  Spirometry
  NYHA heart failure class
  Left ventricular ejection fraction
  Arterial PaCO2 results

  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation

If requesting 95811, indicate whether the request is for PAP titration or split night study
  For a member already on PAP therapy, provide most recent print out for compliance

  Name and address of the facility where the procedure will be performed

  For CPT 95805, Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT), include
notes that Excessive Sleepiness have been excluded

Medical notes documenting the following, when applicable:

  Diagnosis
  Speech-language pathology written evaluation by a qualified speech and language pathologist, including:
  Description of communication impairment (type, severity, language skills, cognition, anticipated course)
  Description of cognitive and physical abilities as they relate to the use of the device
  Rationale for selection of specific device and accessories
  Prior treatments tried, failed, or contraindicated. Include the dates, duration of treatment and reason for discontinuation
  Treating practitioner treatment plan and training schedule
  Documentation of face-to-face encounter, within six months prior to the prescription (written order), from the treating

practitioner including date, when applicable

Speech Generating
Devices

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 35 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Current prescription (written order) from treating physician consistent with and based upon the recommendation of a

qualified speech and language pathologist, including:

Initial or replacement

  Rental or purchase
  Specific HCPCS code(s) for item and each accessory requested
  Equipment make, model and price quotation

Spinal Fusion and Bone
Healing Enhancement
Products

If replacement, current device used, date of initial acquisition, status of warranty and reason for replacement

Medical notes documenting the following, when applicable:

  Condition requiring procedure
  History and co-morbid medical condition(s)
  Member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of

Spinal Fusion and
Decompression

daily living (meals, walking, getting dressed, driving)

  Physical exam, including neurologic exam
  History and duration of previous therapy, when applicable including:

  Physical therapy
  Medications (injections)
  Previous surgery
  Bracing
  Other attempted treatments

  Whether the surgery will be performed with direct visualization or only with endoscopic visualization
  Complete report(s) of diagnostic tests and imaging
  Describe the surgical technique(s) planned 

  Specify the allograft product including brand name(s) to be used

Medical notes documenting the following, when applicable:

  Condition requiring procedure
  History and co-morbid medical condition(s)
  Smoking history/status, including date of last smoking cessation
  Member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of

daily living (ADLs)

  Prior treatments tried, failed, or contraindicated. Include the dates, duration and reason for discontinuation
  Failure of conservative therapy through lack of clinically significant improvement between at least two measurements,

on a validated pain or function scale or quantifiable symptoms despite concurrent conservative therapies

  Progressive deficits with clinically significant worsening based on at least two measurements over time
  Surgical history, including date(s) and outcome(s)
  Disabling symptoms

  Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being
requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
Note: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 36 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted
  Diagnostic image(s) report(s) by a radiologist, including presence or absence of:

  Segment (s) instability
  Spinal cord compression
  Disc herniation
  Nerve root compression
  Quantification of subluxation, translation by flexion, angulation when appropriate
  Discitis
  Epidural abscess
  Scoliosis
  Kyphosis

  Physical exam, including neurologic exam, including degree and progression of curvature (for scoliosis)

  Quantification of relevant muscle strength
  Complete report(s) of diagnostic tests, including:

  Results of biopsy(ies)
  Results of bone aspirate

  Describe the surgical technique(s) planned
  For revision surgery include documentation of:

  Clinical complications
  Relevant laboratory findings
  Relevant imaging
  Prior treatments for complications tried, failed, or contraindicated. Include the dates and reason for discontinuation

Medical notes documenting the following, when applicable:

  Diagnosis
  History of present illness
  Patient performance status, when applicable, using Karnofsky Performance Status (KPS) score or Eastern Cooperative

Oncology Group (ECOG) performance status

  Relevant imaging report(s)
  Proposed treatment plan
  Number of tumors present, their size and location
  Stage of disease
  Where the radiation will be delivered (anatomically) or to which organ, if applicable

Medical notes documenting the following, when applicable:

  Upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
Note: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Reports of all recent imaging studies and applicable diagnostic tests, including:

Stereotactic Body
Radiation Therapy and
Stereotactic
Radiosurgery

Surgery of the Ankle

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 37 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Surgery of the Elbow

Medical Records Used for Reviews
  Microbiological findings
  Synovial exam
  Erythrocyte sedimentation rate (ESR)
  C-reactive protein (CRP)
  Condition requiring procedure
  Symptoms
  Severity of pain and details of functional disability(ies) interfering with activities of daily living
  Pertinent physical examination of the relevant joint
  Consideration of arthroscopic approach
  Co-morbid medical condition(s)
  Prior therapies/ treatments tried, failed, or contraindicated. Include the dates, duration and reason for discontinuation

  Date of previous failed surgery to the same joint, if applicable
  Physician’s treatment plan including pre-op discussion

  Pre-op discussion
  Additional intervention(s) or product(s) to be used during the procedure

  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

  If the location is being requested as an inpatient stay, documentation to support site of care

Medical notes documenting the following, when applicable:

  Condition requiring procedure
  Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
Note: Diagnostic images must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan; faxes will not be
accepted

  Reports of all recent imaging studies and applicable diagnostic tests)

  Microbiological findings
  Synovial fluid exam
  Erythrocyte sedimentation rate (ESR)
  C-reactive protein (CRP)

  Symptoms
  Pertinent physical examination of the relevant joint
  Pain severity, circadian patterns of pain, location of pain, and details of functional disability(ies) interfering with

activities of daily living (ADL)

  Prior therapies/ treatments tried, failed, or contraindicated. Include the dates, duration and reason for discontinuation
  Date of previous failed surgery to the same joint, if applicable
  Physician’s treatment plan, including pre-op discussion

  For revision surgery, also include:

  Details of complication

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 38 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Surgery of the Foot

Surgery of the Hand or
Wrist

Medical Records Used for Reviews

  Complete (staged) surgical plan

Medical notes documenting the following, when applicable:

  Upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Reports of all recent imaging studies and applicable diagnostic tests
  Condition requiring procedure
  Symptoms
  Severity of pain, skin breakdown and details of functional disability(ies) impairment to include impact on activities of

daily living (ADLs)

  Pertinent physical examination of the relevant joint
  Co-morbid medical condition(s)
  Prior therapies/ treatments (e.g. padding, orthotic, footwear, physical therapy, activity modification, medications, etc.)

tried, failed, or contraindicated. Include the dates, duration of treatment and reason for discontinuation

  History of previous surgery(ies), if applicable

  Physician’s treatment plan including:

  Pre-op discussion
  Additional intervention(s) or product(s) to be used during the procedure

  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

  If the location is being requested as an inpatient stay, provide documentation to support site of care

Medical notes documenting the following, when applicable:

  Upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Reports of recent imaging studies and applicable diagnostic tests, including:

  Microbiological findings
  Synovial exam
  Erythrocyte sedimentation rate (ESR)
  C-reactive protein (CRP)
  Condition requiring procedure
  Severity of pain and details of functional impairment to include impact on activities of daily living (ADLs)

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 39 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Pertinent physical examination of the relevant joint
  Co-morbid medical condition(s)
  Prior therapies/ treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation
  History of previous surgery(ies) to the same joint, if applicable
  Physician’s treatment plan including pre-op discussion

  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

Surgery of the Hip

  If the location is being requested as an inpatient stay, provide documentation to support site of care

Medical notes documenting the following, when applicable:

  Complete diagnostic imaging report(s) that are separate and distinct from the professional component of an evaluation

and management office visit

  For femoroacetabular impingement (FAI) syndrome (CPT codes 29914, 29915, and 29916), also include radiographic

reports of presence and severity of cartilage damage using Tönnis or Outerbridge grading
In addition, upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery
is being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon
may be of benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification or member's name and ID number on the image(s)

Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Condition requiring procedure
  Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals,

dressing, driving, walking) using a standard scale; such as Western Ontario and McMaster Universities Arthritis Index
(WOMAC) or Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)

  Physician’s treatment plan, including pre-op discussion
  Pertinent physical examination of the relevant joint
  Co-morbid medical conditions (cardiovascular diseases, hypertension, diabetes, cancer, pulmonary diseases,

neurodegenerative diseases)

  Prior therapies/treatments tried, failed, or contraindicated; include the dates and reason for discontinuation

  Date of failed previous hip fracture fixation, if applicable
  If the location being requested is an inpatient stay, provide medical notes to support at least one of the following:

  Surgery is bilateral
  Member has significant co-morbidities; include the list of comorbidities and current treatment
  Member does not have appropriate resources to support post-operative care after an outpatient procedure; include

the barriers to care as an outpatient

Medical notes documenting the following, when applicable:

  Complete diagnostic imaging report(s) that are separate and distinct from the professional component of an evaluation

and management office visit, including:

  Documented closure of skeletal plates (age less than 18 years)
  Presence or absence of focal full-thickness articular cartilage defect
  Size and location of focal cartilage defect

Surgery of the Knee

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 40 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Outerbridge grade
  Joint space and alignment
  Ligament tear location and grade

In addition, upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery
is being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon
may be of benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Reports of all recent applicable diagnostic tests, including:

  Microbiological findings
  Synovial exam
  Erythrocyte sedimentation rate (ESR)
  C-reactive protein (CRP)
  Condition requiring procedure
  Symptoms
  Severity of pain and details of functional disability(ies) interfering with activities of daily living
  Cause of defect; e.g., acute or repetitive trauma
  Pertinent physical examination of the relevant joint
  Co-morbid medical condition(s)

  Prior therapies/ treatments tried, failed, or contraindicated. Include the dates, duration, and reason for discontinuation
  Date of failed previous surgery to the same joint, if applicable)
  Physician’s treatment plan including:

  Pre-op discussion
  Additional intervention(s) or product(s) to be used during the procedure

  Consideration of arthroscopic approach, if applicable
  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

  If the location being requested is an inpatient stay, provide medical notes to support at least one of the following:

  Surgery is bilateral
  Member has significant co-morbidities; include the list of comorbidities and current treatment
  Member does not have appropriate resources to support post-operative care after an outpatient procedure; include

the barriers to care as an outpatient

Surgery of the Shoulder  Medical notes documenting the following, when applicable:

  Pertinent physical examination of the relevant joint
  Severity of pain and details of functional disability(ies) interfering with activities of daily living (ADLs)
  Upon request, we may require the specific diagnostic image(s) that shows the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic images must be labeled with the:

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 41 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted

  Reports of all recent imaging studies and applicable diagnostic tests including when applicable:

a.  Microbiological findings
  Synovial fluid cytology
  Erythrocyte sedimentation rate (ESR)
  C-reactive protein (CRP)

  Condition requiring procedure, including relevant past history with dates
  Physician’s treatment plan including pre-op discussion
  Feasibility of arthroscopic approach
  Co-morbid medical condition(s)
  Prior therapies/treatments tried, failed, or contraindicated; include the dates, duration, and reason for discontinuation

  Member has the ability to participate in post-surgical rehabilitation
  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

Surgical and Ablative
Procedures for Venous
Insufficiency and
Varicose Veins

If the location is being requested as an inpatient stay, provide medical notes to support site of service

Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Documentation of signs and symptoms; including onset, duration, frequency, and which extremity (right, left or both)
  Pain or other symptoms that interfere with activities of daily living (ADL) related to vein disease including duration
  Functional disability(ies), as documented on a validated functional disability scale, interfering with the ability to stand or

sit for long periods of time (preparing meals, performing work functions, driving, walking, etc.)

  Relevant medical history, including:
  DVT (deep vein thrombosis)
  Aneurysm
  Tortuosity

  Physical exam, including:

  Which extremity (right, left or both)
  Vein(s) that will be treated (i.e., great saphenous vein (GSV) and small saphenous vein (SSV), etc.)
  Vein diameter including the specific anatomic location where the measurement was taken (i.e., proximal thigh,

proximal calf, etc.)

  Duration of reflux including the position of member at the time of measurement and the anatomic location where

the measurement was taken

  Reports of recent imaging studies and applicable diagnostic tests
  Prior non-invasive treatments of the veins that have been tried/ failed or were contraindicated. Include the dates,

duration and reason for discontinuation
  History of prior treatment complications (e.g. recurrent bleeding or significant hemorrhage) including the dates of
occurrence
  History of previous relevant vein procedure(s), if applicable

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 42 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Proposed treatment plan with procedure code, including specific vein(s) that will be treated , which extremity (left, right, or both), and date of procedure for each vein
to be treated

Sympathetic Blockade

Total Artificial Disc
Replacement for the
Spine

Medical notes documenting the following, when applicable:

  Diagnosis
  History of the medical condition(s) requiring treatment or surgical intervention
  Documentation of signs and symptoms; including onset, duration, and frequency
  Physical exam
  Relevant medical history
  Treatments tried, failed, or contraindicated. Include the dates and reason for discontinuation

For Cervical and Lumbar Surgery
Medical notes documenting the following, when applicable:

  Diagnosis
  Specific requested procedure
  History of the medical condition(s) requiring treatment or surgical intervention, including:

  Level(s) of motor deficit
  Level(s) of sensory deficit
  Extremity weakness, numbness, pain, or loss of dexterity including unilateral or bilateral
  Gait disturbance, including investigation for other etiologies
  Bowel or bladder dysfunction, including investigation for other etiologies

  History or signs of infection, malignancy, facet arthritis or spine instability at the level of disc replacement request
  Documentation of signs and symptoms; including onset, duration, and frequency
  Physical exam, including:
  Spasticity, including investigation for other etiologies
  Relevant medical and surgical history, including:

  Osteoporosis or osteopenia
  Spondylosis, including severity and level
  Ankylosing spondylitis
  Rheumatoid arthritis
  Ossification of the posterior longitudinal ligament
  Presence or absence of fracture with deformity

  Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being

requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of
benefit to select the optimal images
NOTE: When requested, diagnostic image(s) must be labeled with:

  The date taken
  Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Upon request, diagnostic imaging must be submitted via the external portal at www.uhcprovider.com/paan; faxes will
not be accepted faxes will not be accepted
  Treatments tried, failed, or contraindicated, include the dates and reason for discontinuation
  Current medications used to treat condition, include start date
  Reports of all recent imaging studies and applicable diagnostics, including results of imaging including specific spinal
levels with pathology

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 43 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Physician treatment plan
  For Lumbar Surgery, in addition to the above, provide medical notes documenting the following, when applicable:

  Provide psychosocial-behavioral
  Documentation of instability (listhesis-, spondylolisthesis and grade)
  Provide the surgical technique to be used and the number of levels involved and their location

Transarterial
Radioembolization
(TARE)/ Selective Internal
Radiation Therapy (SIRT)
for the Treatment of
Malignant Cancers of the
Liver
Transcatheter Heart
Valve Procedures

Medical notes documenting the following, when applicable:

  Diagnosis
  Eastern Cooperative Oncology Group (ECOG) score
  Location of malignancy
  Feasibility of resection

Is the condition refractory to or relapsed following systemic chemotherapy

  Physician’s treatment plan including plan for liver transplant

For ALL transcatheter valve procedures, provide medical notes documenting the following, when applicable:

  Name of device being used, if available
  Diagnosis
  Co-morbidities
  Treatments tried, failed, or contraindicated
  Physician treatment plan

In addition to the above, provide medical notes documenting the following for Aortic Heart Valve

  New York Heart Association (NYHA) Classification
  One of the following:

  Mean aortic valve gradient
Peak aortic jet velocity
Aortic valve area

  Member has engaged in a Shared Decision Making conversation with an interventional cardiologist and an

experienced cardiothoracic surgeon who have determined procedure is appropriate

  Facility where procedure will be performed

In addition to the above, provide medical notes documenting the following for Aortic Transcatheter valve-in-valve
(ViV) replacement

  Name of failed device
  Surgical risk using PROM score

In addition to the above, provide medical notes documenting the following for Pulmonary Heart Valve

  Right ventricular outflow tract (RVOT) gradient or pulmonary regurgitation rate

Treatment of
Temporomandibular
Joint Disorders

Medical notes documenting the following, when applicable:

  History of medical conditions requiring treatment or surgical invention including:
  Signs and symptoms; including onset, duration, and frequency
  All recent, related, supporting imaging must be diagnostic quality and labeled with the:

a.  Date taken
b.  Applicable case number obtained at time of notification or member’s name and ID number
NOTE: Images must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted

  Recent applicable imaging and diagnostics
  Prior therapies/treatments/surgeries to the same joint tried, failed, or contraindicated; include the dates, duration of

treatment and reason for discontinuation

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 44 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews
  Treating physician’s plan of care
  For revision surgery, also include:

  Details of complication
  Complete (staged) surgical plan

Upper Extremity
Prosthetic Devices

Medical notes documenting the following, when applicable:

  Vendor Coversheet with a narrative describing the request
  Vendor invoice listing the HCPCS codes, make/ model description, indicate if the item is right or left. Include, make,

model and pricing for unlisted codes.

  Other healthcare professional notes if applicable (i.e. occupational therapist)
  Current prescription
  Professional qualification and training of the healthcare professional who performed the member evaluation
  Physician office notes including documentation of:

  History related to the prosthetic request
  Co-morbidities
  Specify absent limb including the date, level and etiology of amputation
  Documentation of handedness
  Physical examination to include residual limb length and limb volume stability, skin integrity of residual limb,

examination of contralateral limb, manual muscle testing and ROM examination

  Describe limitations to activities of daily living (ADLs) and instrumental ADLs (IADLs) without the prosthetic
  Prosthetist notes to include medical justification for each of the requested prosthetic components. Also, if
applicable, documentation should include a description of the current prosthesis, to include the age and
components of the current prosthetic arm

  Motivation to use device
  Member ability to tolerate prosthetic weight
  Member willingness and ability to participate in the training for the use of the prothesis (i.e. prosthetic rehabilitation)
  Member cognitive ability to operate prosthetic
  Environment in which the device will be used

  Specify whether the prosthetic is an initial, replacement, preparatory or definitive or a request to upgrade
  Rehabilitation plan
  Final prosthetic proposal from ordering physician

  For replacement prosthesis, also include:

  Age of the current prosthesis
  Reason for replacement
  Estimated cost of adjustment or repair if applicable

  For a socket replacement include age of the current socket, reason for replacement, and comparative residual limb
measurements showing a change in residual limb size, what adjustments have been made to the current socket to
improve fit

Vagus and External
Trigeminal Nerve
Stimulation

Medical notes documenting the following, when applicable:

  Specific diagnosis/condition
  Medical and surgical history
  Prior pharmacological agents tried to which the seizures have been refractory
  Frequency of seizures

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 45 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

Service

Medical Records Used for Reviews

  Documentation as to whether the member is not a candidate for epilepsy surgery, has failed surgery or refuses

epilepsy surgery after Shared Decision Making discussion

  Quality of Life assessment with quantifiable measures of date-to-life besides the occurrence of seizures

Video
Electroencephalographic
(VEEG) Monitoring and
Recording

Medical notes documenting the following, when applicable:

  Current order
  Name and tax ID number of the servicing provider
  Physician office notes that include

  Member diagnosis
  History
  Seizure treastments and medication tried, failed or contraindicated, include dates, duration and reason for

discontinuation

  Results of all recent imaging and diagnostic tests, including:
Routine or spot electroencephalogram (EEG)
Laboratory tests
Neuro imaging

  Seizure-related hospitalization(s), including dates
  Seizure semiology and frequency
  All medications the member is taking

Whole Exome and Whole
Genome Sequencing

If inpatient is requested, provide documentation to support site of care

Medical notes documenting the following, when applicable:

  Personal history of the condition, if applicable, including age at diagnosis
  Complete family history (usually three-generation pedigree) relevant to condition being tested
  Genetic testing results of family member, if applicable, and reason for testing
  Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing
  Any prior genetic testing results
  How clinical management will be impacted based on results of genetic testing
  Genetic counseling (if available)

Medical Records Documentation Used for Reviews
MRDUR01.05

Page 46 of 46
Effective 03/01/2025

Proprietary Information of UnitedHealthcare. Copyright 2025 United HealthCare Services, Inc.

