Is it necessary to upload clinical documents as attachments with our requests?

While uploading documents may not technically be required for all authorizations, we recommend that you do this every time. In the case that we need to review the request in more detail, this will minimize the need to reach out to obtain that information. The table below outlines what documentation is required for our review.

 

Prior Authorization List (PAL) Category Required documentation for review Related resources (if applicable)
Therapy (physical, occupational, and speech)
  • Clinical documentation to support the visits requested for approval.
  • For subsequent therapy requests: provide documentation demonstrating clinical improvement from previous therapy.
Viscosupplementation
  • Both the CPT code for the injection and the J-code for the preferred drug being used.
  • All other non-preferred drug codes must be submitted through Humana separately.
  • Provide clinical documentation to support viscosupplementation injection.
Epidural Steroid Injections (ESI)
  • Imaging and documentation of prior conservative treatment and duration of treatment.
Facet Injections
  • Updated imaging to confirm that there is no non-facet pathology.
  • Documentation of conservative treatment and duration.
Sacroiliac (SI) Joint Injections
  • Three (3) provocative examination maneuvers of the sacroiliac joint(s).
Orthopedic surgeries: hip, knee, and shoulder arthroscopy (Commercial)
  • Documentation of conservative treatment for 12 consecutive weeks: formal PT, home exercise, prior corticosteroid injection, NSAID’s if appropriate.

 

Orthopedic surgeries: hip, knee, and shoulder arthroscopy (Medicare)
  • Documentation of conservative treatment: formal PT, home exercise, prior corticosteroid injection, NSAID’s if appropriate.
 
Orthopedic Surgeries: Hip, Knee and Shoulder Arthroplasty
  • Most recent detailed weight-bearing imaging results with Tonnis or Kellgren Lawrence classification.
 
Spinal fusion & Decompression
  • Documentation of instability present or reason for concern for iatrogenic instability with decompression.
Kyphoplasty & Vertebroplasty
  • Include age of fracture, degree of compression, imaging, and neurologic exam or consult.

 

Foot Surgeries: Bunionectomy and Hammertoe
  • Documentation of prior conservative treatment: formal PT, home exercise, or NSAID’s if appropriate.
  • Findings of foot radiograph(s).
 
Spinal cord stimulators
  • Documentation of the patient's response to the trial.
  • Multidisciplinary team evaluation(s).
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