To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. For information on general documentation requirements, including an applicable local coverage determinations/local coverage articles, refer to the Prior authorization (PA) program for certain hospital outpatient department (OPD) services - general documentation requirements article.
The hospital OPD is responsible for submission of the prior authorization request (PAR) and all documentation to Medicare on behalf of the Medicare patient. Physicians/providers must ensure the hospital OPD has all necessary medical record documentation to support the prior authorization request. In some relationships the physician may submit the request on behalf of the hospital OPD.
To support medical necessity, medical records should contain at least the following information.
History and physical
Chief complaint as related to current level of vision
Progress of complaint such as anatomic, physiological ocular problems or physical impairment
Previous treatment
Visual field testing (if applicable) or documentation of visual impairment
Prosthesis difficulties (if applicable)
Lower lid
Photographs showing
Frontal graze in primary position
Lateral views
With eyeglasses (if applicable)
Upper lid
Photographs showing
Frontal views with central corneal reflex
Oblique photos
History and physical
Chief complaint as it relates to symptoms of dystonia, eye muscles, migraines, sialorrhea and blepharospasm as applicable
Include any off-label indications (if applicable) and any other previous treatments
Dosage and frequency of planned injections
History and physical
Chief complaint such as chronic conditions related to excessive fat and skin of the abdomen
Example infections and previous treatment
Physical description of the panniculus
Documented weight loss (if applicable)
Photographs may be required to support justification
History and physical
Chief complaint as it relates nasal deformities and/or airway obstruction due to trauma, congenital defect, related conditions to (example: epistaxis) or disease
Documentation of the response to conservative medical management
Documentation necessary related to trans nasal surgical procedures
Photographs
Frontal view
Lateral view
“Worms” eye view
Documentation must include a plan of care, for a 90-day episode of care, that supports the evaluation of the patient including:
A history and physical examination
The timing of an intervention(s) must be outlined
Serial ablation procedures on the same leg within a 90-day episode of care must clearly be supported in the documentation based on patient specific clinical information that the ablation procedures cannot be performed on a single day.
CEAP clinical classification
VCSS
The plan of care must include the date(s) of the examination and diagnostic evaluation.
Conservative therapy (2-4 weeks) if applicable
Formal duplex scan
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