Medical Record Requirements for Pre-Service Reviews This document lists medical record requirements for pre-service reviews. These requirements are developed using the clinical criteria in UnitedHealthcare medical policies in conjunction with the guidance provided by UnitedHealthcare physicians and pharmacists with experience in reviewing pre-service requests for coverage. These medical record requirements were developed in an effort to decrease the need for repeated requests for additional information and to improve turnaround time for coverage decisions. Please prepare the suggested materials in advance. We reserve the right to request more information, if necessary. Medical record requirements for case review(s) may vary among various UnitedHealthcare Commercial, UnitedHealthcare Community Plan and UnitedHealthcare Medicare Advantage benefit plans. Please review the requirements for notifications and prior authorization requests at UHCprovider.com/priorauth. These medical record requirements are provided for reference purposes only and may not include all services or codes. Listing of a service or code in this document does not imply that it is a covered or non-covered health service or code. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws. This document 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 service category from the Table of Contents to jump to the applicable section of this document. Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc. Page 1 of 141 Table of Contents Click a service category below to jump to the applicable section of this document. ® Ablative Treatment for Spinal Pain .................... 5 Cardiac Catheterization With or Without Exondys 51 (eteplirsen) ............................... 33 Abortion ......................................................... 5 Angiography ................................................. 20 External Insulin Pump .................................... 34 ® Accidental Dental Services ............................... 5 Cardiac Event Monitoring ................................ 21 Fabrazyme (agalsidase beta) ........................ 34 ® Actemra (tocilizumab) .................................... 5 Catheter Ablation for Atrial Fibrillation .............. 21 Facet Joint Injections for Spinal Pain for Exchange ® Adagen (pegademase bovine) ......................... 6 Certified Nursing Assistant (CAN) or Home Health Plans ........................................................... 35 ® Adakveo (crizanlizumab-tmca) ........................ 6 Aide for Adults 21 and Older for Florida Factor - Von Willebrand Factor (recombinant) .. 35 Airway Clearance Devices................................. 7 Community Plan ............................................ 21 Factor IX ...................................................... 35 ® Akynzeo (netupitant) ..................................... 7 Chimeric Antigen Receptor (CAR) T-Cell Therapy Factor –Products ........................................... 36 ® Aldurazyme (laronidase) ................................ 7 ................................................................... 21 Factor –Products for KS Community Plan ......... 36 ® Alglucosidase alfa ............................................ 7 Cimzia (Certolizumab Pegol) ......................... 22 Factor VIII ................................................... 36 ® ® Alimta (pemetrexed) ..................................... 8 Cinqair (reslizumab) ..................................... 22 Factor VIII (plasma-derived) / von Willebrand Alpha1 Proteinase Inhibitor ............................... 8 Clinical Trials ................................................ 23 Factor Complex (plasma-derived) ................... 38 Ambulance Service ‒ Non-Emergency Air Cochlear Implants & Other Auditory Implants .... 23 Factor X ....................................................... 38 Transport ....................................................... 9 Congenital Heart Disease - Diagnostic and Factor XIII ................................................... 38 Amondys 45™ (Casimersen).............................. 9 Therapeutic Services ...................................... 23 Fasenra® (benralizumab) ............................... 39 Antiemetics For Oncology ............................... 10 Continuous Glucose Monitoring (CGM) .............. 23 Fertility Preservation for Iatrogenic Infertility .... 39 Apheresis ..................................................... 10 Continuous Positive Airway Pressure (CPAP) ..... 24 Fibrinogen Concentrate (plasma-derived) ......... 39 Aranesp® (darbepoetin alfa) ........................... 10 Cosmetic & Reconstructive .............................. 24 Firazyr® (icatibant) ....................................... 40 Arcalyst® (rilonacept) .................................... 10 Crysvita® (burosumab-twza) ........................... 25 Functional Endoscopic Sinus Surgery (FESS) .... 40 Attended Polysomnography (Sleep Study) for Custom Ankle-Foot Orthoses (AFO) and Knee- Functional Neuromuscular Stimulation (FES) .... 41 Evaluation of Sleep Disorders ......................... 11 Ankle-Foot Orthoses (KAFO) ........................... 25 Gamifant® (emapalumab-lzsg) ....................... 41 Autologous Chondrocyte Transplantation .......... 11 Custom Knee Orthotic (KO) ............................ 26 Gastrointestinal Motility Disorders, Diagnosis and Autologous Chondrocyte Transplantation - Implant Decompression Unspecified Nerves .................. 26 Treatment .................................................... 42 material ....................................................... 12 Deep Brain and Cortical Stimulation ................. 26 Gastrointestinal Pathogen Nucleic Acid Detection Automatic External Defibrillator ...................... 12 Denosumab .................................................. 27 Panel Testing For Infectious Diarrhea .............. 42 Balloon Sinus Ostial Dilation (Sinuplasty) ......... 13 Denosumab (Prolia®) for KS Community Plan .... 27 Gender Dysphoria ......................................... 42 Bariatric Surgery ........................................... 14 Drug Testing for Exchange Plans ..................... 28 Genetics and Molecular Pathology Testing Bed Enclosures ............................................. 14 Elaprase® (idursulfase) .................................. 28 (Including BRCA) .......................................... 43 Beds and Mattresses...................................... 15 Elaprase® (idursulfase) for KS Community Plan Givlaari® (givosiran) ...................................... 44 Beds and Mattresses for Exchange Plans .......... 15 Members ...................................................... 29 Glatopa® (glatiramer acetate)......................... 44 Behavioral Health Services ............................. 15 Electric Tumor Treatment Therapy (TIFT) ......... 29 Habilitative Services and Outpatient Rehabilitation Benlysta® (belimumab) .................................. 15 Electrical and Ultrasound Bone Growth Stimulators Therapy for Exchange Plans ........................... 45 Blepharoplasty, Blepharoptosis, and Brow Ptosis ................................................................... 30 Hearing Aids and Devices Including Wearable, Repair ......................................................... 16 Electrical and Ultrasound Bone Growth Stimulators Bone-Anchored and Semi-Implantable ............. 47 Bone or Soft Tissue Healing and Fusion for Exchange Plans ........................................ 30 Hemlibra® (emicizumab-kxwh) ....................... 47 Enhancement Products .................................. 16 Electroencephalographic (EEG) Monitoring and Hemophilia clotting factor, not otherwise classified Botulinum Toxins A and B .............................. 17 Video Recording ............................................ 30 .................................................................. 47 Breast Reconstruction Post Mastectomy and Empliciti® (elotuzumab) for KS Community Plan Herceptin® (trastuzumab) .............................. 48 Poland Syndrome .......................................... 18 Members ...................................................... 31 Herceptin® (trastuzumab) for KS Community Plan Breast Reduction Surgery ............................... 19 Enbrel® (etanercept) ...................................... 31 .................................................................. 48 Breast Repair/ Reconstruction Not Following Enteral Nutrition (Tube Feedings) .................... 31 Hereditary Angioedema (HAE), Treatment and Mastectomy .................................................. 19 Entyvio® (vedolizumab) .................................. 32 Prophylaxis .................................................. 48 Brineura® (cerliponase alfa) ........................... 19 Epoetin alfa .................................................. 32 Home Health Care Services ............................ 49 Camptosar® (irinotecan) for KS Community Plan Epoprostenol ................................................. 32 Home Health Care Services for KS Community members ..................................................... 20 Erbitux® (cefuximab) ..................................... 33 Plan ...........................................................