Arthroscopy & Arthroplasty

Depending on the procedure codes entered for authorizations, the following documentation may be required. In very few circumstances, additional information that is not listed may be requested.

For every authorization, regardless of service, please include an office visit note with TWO (2) patient identifiers.

We encourage all users to print this checklist and utilize it when submitting hip, knee, and shoulder arthroscopy & arthroplasty. 

Documentation Details
Advanced imaging
  • MRI and/or CT scan
  • Dated imaging report


Include date, type of x-ray, and findings

Patient information

  • Body mass index (BMI)
  • Most recent office visit note(s)
  • Current tobacco use status + history
Outcome of prior treatments List all treatments, outcomes, and dates
Surgical plan/ order  
Non-operative treatments
Documentation of attempted weight loss

For patients with BMI >40

Conservative therapy

Include duration and dates of treatment within the last 12 months

  • Ambulatory assistive device
  • Activity/ lifestyle modifications
  • Home exercise program
  • Orthotics or braces for knee (if medically appropriate)
Physical therapy

Including home exercise program w/ duration and dates of PT

Intra-articular injections

If medically appropriate and not contraindicated


Nonsteroidal anti-inflammatory drugs [NSAIDs], non-narcotic analgesics (if medically appropriate and not contraindicated)

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