6 Documentation Gaps That Slow Down Utilization Review

Utilization review (UR) plays a key role in making sure patients get medically necessary care while keeping healthcare costs in check. But in practice, most delays don’t come from “denials” as much as they come from incomplete or unclear documentation.

What Utilization Review Evaluates

UR evaluates three core questions:

1. Is the service medically necessary?
2. Is the support documentation complete?
3. Does it match accepted medical criteria and guidelines?

If any of these are unclear or missing, the request gets sent back for more information, and that adds days to the process.

Documentation Gaps That Slow Down Utilization Review

Clinical Rationale

One of the most common documentation gaps is the lack of a clear clinical rationale. In many cases, the request includes a diagnosis and a service, but it does not clearly connect the patient’s symptoms, exam findings, and the reason the service is needed at this specific time.

When that link is missing, reviewers cannot confidently determine medical necessity, which often results in the request being paused or sent back for additional information. A simple way to prevent this is to add one or two clear sentences at the beginning of the documentation explaining why the service is medically necessary right now.

Objective Findings

Another frequent issue is the absence of objective clinical findings. Lab results, imaging reports, measurable deficits, and documented exam findings are often required to support medical necessity.

Without objective evidence, reviewers cannot verify severity or confirm that guideline criteria are met. This creates delays because they must request additional documentation. The easiest fix is to attach the relevant reports and clearly reference the key findings within the request itself.

Documentation of Conservative Care

Many treatment guidelines expect conservative care to be attempted first, when clinically appropriate. However, documentation often fails to clearly show what treatments were tried, how long they were tried, and whether they were effective.

When that history is vague or incomplete, the reviewer may not be able to confirm that the next step in care is justified. To avoid this, briefly summarize prior treatments and clearly document the patient’s response, including why the treatment did not resolve the issue.

Functional Impact

Functional impact is often overlooked in documentation. Reviewers need to understand how the condition affects the patient’s daily activities, mobility, or ability to work. Without this information, it can be difficult to assess severity and necessity.

Including a short description of baseline function compared to current limitations provides valuable context and helps support the request. Even a few simple statements about activity restrictions or impairment can strengthen the documentation significantly.

Vague Plan of Care

A request may describe a service but fail to define the details of the plan. Missing information such as frequency, duration, measurable goals, or expected outcomes makes it difficult for reviewers to authorize care.

Utilization review requires clarity about what is being approved. To prevent UR delays, clearly state how often the service will occur, how long it will continue, and what improvement is expected, along with how that improvement will be measured.

Not Mapping to Guideline Criteria

Finally, many requests do not clearly show how they meet medical necessity or evidence-based guideline criteria. Reviewers are required to compare documentation to specific standards, and if the connection is not obvious, they must ask for clarification. This adds time to the process.

A simple way to strengthen a request is to include a brief statement explaining how the clinical findings meet the relevant criteria. Even a short summary linking documentation to guideline requirements can make the review process much smoother.

Why Utilization Review Matters

Healthcare spending in the U.S. has grown dramatically, from about $1.4 trillion in 2000 to over $5.3 trillion in 2024. That means nearly one out of every five dollars in the economy is spent on health care.

At the same time, research shows that well-structured utilization review programs can reduce unnecessary hospital admissions by about 13%, inpatient days by about 11%, and total medical expenditures by about 6%, meaning review processes do help improve efficiency and control costs.

When documentation is clear and complete, UR doesn’t just move faster, it helps make care better and more affordable for everyone.

Missed the webinar or want to continue the discussion? Our utilization review specialists are available to review your current program and identify opportunities to streamline approvals and strengthen medical necessity support. Talk to our team today.

Check out our sources:

Rakshit, Shameek, et al. “How Has U.S. Spending on Healthcare Changed Over Time?” Peterson-KFF Health System Tracker, 22 Jan. 2026, www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/.

Wickizer, T. M. “Does Utilization Review Reduce Unnecessary Hospital Care and Contain Costs?” Medical Care, vol. 27, no. 5, 1989, www.jstor.org/stable/3765229.