Clinical Information to Determine Medical Necessity

Covered: this guideline governs documentation requirements for any request needing a medical-necessity review (no specific diagnoses/services listed); excluded: requests with incomplete or illegible records will not be approved. Key requirements: submit legible, sufficiently detailed records—recent history and physical, labs, imaging, pathology, procedure reports, and other treating-provider notes—that clearly document the patient’s current clinical status or medical necessity cannot be established.

"Note: No specific diagnoses, conditions, or clinical scenarios are listed in this document; guidance applies broadly to requests submitted for medical necessity review."

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