Prior Authorization Request (Aquatic Therapy)

Date: [Date]

Patient: [Patient name, DOB, Member ID]

Primary Diagnosis (ICD-10): [Primary diagnosis code and description] | Relevant Comorbidities: [Comorbid conditions impacting plan and safety]

Payer/Plan: [Payer name / Plan name]

Request Type: [Initial / Extension / Additional Visits]

Rendering Provider: [Therapist name, credentials, NPI] | Facility: [Facility name, address] | Phone/Fax: [Phone] / [Fax]

Referring Provider: [Referrer name, credentials, NPI] | Referral Date: [Date / Not available - requested]

Request Summary

• Service requested: [Aquatic therapy / Therapeutic exercise in water] (Include CPT codes if required by payer)
• Total visits requested: [Number]
• Frequency and duration: [Sessions/week] x [Weeks]
• Planned minutes per visit: [Minutes]
• Place of service: [Outpatient clinic pool / Hospital outpatient / Other]
• Supervision model: [1:1 skilled care / Concurrent with direct supervision]
• Transition plan: [Brief statement of progression criteria and timing for transition to land-based therapy]

Medical Necessity Summary

[Concise summary paragraph integrating: primary diagnosis with severity and chronicity; 2–3 key objective deficits with numeric values; 1–2 functional consequences on specific ADLs/work/mobility; rationale why aquatic therapy is required now versus land-based care including any attempted land care and response; requested dose; and expected measurable outcomes.] (5–8 sentences; payer-oriented, objective, and measurable)

Clinical Background

History and Prior Treatment

• [Most recent event: onset/mechanism or post-op status; current phase/precautions]
• [Pertinent imaging or operative details with dates and weight-bearing status]
• [Prior treatments: medications, injections, bracing, land-based PT with dates and objective response]
• [If land-based PT attempted: specific intolerance documented with objective measures]
• [If land-based PT not attempted: clinical rationale why not yet appropriate with objective findings]
• [Home exercise program adherence and response]

(If prior care records unavailable, state: "Prior conservative care: unknown/unavailable - requested from referring clinic")

Objective Examination Findings

• Pain: [Location], [Current x/10], [Best/Worst x/10], [Irritability/24-hr pattern]
• Range of Motion: [Joint/plane]: [A/PROM degrees], [End-feel/limitations]
• Strength (MMT): [Muscle group]: [Grade/5] ([Functional correlate])
• Gait/Mobility: [Assistive device], [Distance tolerance], [Observed deviations], [Weight-bearing status]
• Balance/Fall Risk: [TUG / Berg / 5xSTS / Gait speed]: [Score], [Date]; [Fall history past 12 months]
• Endurance: [6MWT or symptom-limited activity]: [Distance/time], [Limiting symptoms]
• Edema: [Circumferential measures with landmarks in cm] (Include comparison to contralateral or prior)
• Skin integrity: [Intact / Location, size, drainage if compromised]
• Patient-reported outcome: [Instrument]: [Baseline score], [Date], [Retest interval]
• Performance-based outcome: [Measure]: [Baseline score], [Date], [Retest interval]

Functional Limitations

• [Transfers: assistance level, device, time or repetitions]
• [Ambulation: distance, terrain tolerance, community participation]
• [Stairs/curbs: number of steps, rail use, assistance level]
• [Self-care: bathing/dressing/toileting specifics]
• [Work/sport demands: task-specific limitations]
• [Safety: fall risk indicators, near-falls/falls, need for guarding]

Rationale for Aquatic Therapy

Why Land-Based Therapy Is Insufficient Now

• [Patient-specific load intolerance: pain escalation, swelling increase, or compression sensitivity with land loading at specified task/intensity]
• [High fall risk/unsafe gait mechanics requiring offloading: objective indicators]
• [Post-op or medical precautions limiting safe land dosing]
• [Other barriers: severe fear/guarding, obesity/deconditioning with objective signs]

(Document what land trial was attempted and outcomes, or why a land trial is currently unsafe)

Water Properties Matched to Patient Deficits

• Buoyancy/offloading: [Planned immersion depth] to achieve [approximate % body-weight support] for [reduced joint compression / graded weight-bearing]
• Viscosity/turbulence: [Scalable resistance and slowed movement for strengthening/control of specific joints/movements]
• Hydrostatic pressure: [Edema management / proprioceptive input] supporting [specific outcome]
• Thermal effects: [Pain reduction / muscle relaxation enabling ROM gains / functional task practice] (Include only if warm water pool)

Skilled Therapy Requirement

• [Clinical selection of safe immersion depth, devices, and entry/exit method]
• [Close guarding, safety cueing, and real-time technique correction]
• [Dosage titration based on symptom response and objective measures]
• [Progression decisions toward land-based loading with documented thresholds]

Plan of Care and Goals

Requested Services

• Frequency: [Sessions/week]
• Duration: [Weeks]
• Total visits: [Number]
• Dose rationale: [Justification tied to severity and expected progression] (If above typical frequency/duration, provide explicit justification)

Planned Interventions

• [Aquatic therapeutic exercise: strengthening/ROM/endurance]
• [Aquatic gait training: depth-graded weight-bearing, mechanics, speed]
• [Balance/proprioceptive drills]
• [Functional training: sit-to-stand, step-ups, task-specific practice]
• [Patient education: self-management, pacing, symptom response]
• [Home exercise program: complementary land-based components]

Goals

• Short-term (2–4 weeks): [SMART goals for tolerance, safety, early functional gains with baseline and target values]
• Long-term (6–12 weeks): [SMART goals for community mobility/work participation with target outcome scores]

Transition Criteria

• [Land pain with loading ≤ x/10 during specified tasks]
• [No swelling increase > x cm within 24 hours of land session]
• [Gait speed ≥ x m/s or TUG ≤ x sec]
• [Tolerates ≥ x minutes of land exercise without symptom flare]
• [Projected transition timing]

Reassessment Schedule

• Measures: [Outcome measures to retest]
• Cadence: [Every x visits or every x days]
• Decision rules: [Continue/progress if improving; modify plan or transition to land-only if plateau; reduce dose or escalate medically if adverse response]

Safety Screening

• Open wounds/nonhealing ulcers: [Yes / No / Not assessed - will confirm before first visit]
• Incontinence (uncontrolled): [Yes / No / Not assessed - will confirm before first visit]
• Uncontrolled seizure disorder: [Yes / No / Not assessed - will confirm before first visit]
• Severe aquaphobia: [Yes / No / Not assessed - will confirm before first visit]
• Skin infection/communicable condition: [Yes / No / Not assessed - will confirm before first visit]
• Chemical sensitivity: [Yes / No / Not assessed - will confirm before first visit]
• Cardiopulmonary monitoring required: [Yes / No]; Vitals plan: [Pre/post monitoring as indicated]
• Transfer/access needs: [Stairs / Ramp / Lift]; [Assistance level]
• Supervision confirmed: [1:1 direct skilled supervision]

Supporting Documentation Available

• Initial Evaluation: [Date]
• Plan of Care: [Date]
• Recent Progress Note: [Date] (For extension requests)
• Relevant Imaging: [Study, Date]
• Operative Note/Precautions: [Date] (If applicable)
• Outcome Measure Scores: [Instrument – score, Date]

Provider Attestation

Therapist: [Name, credentials, NPI]

Signature: ____________________________ Date: [Date]

Contact for Peer-to-Peer Review: [Phone] / [Fax]

Progress and Continued Medical Necessity

(Include this section for extension or additional visit requests only)

• Care to date: [Dates]; [Aquatic visits completed]; [Land visits completed]
• Objective change from baseline: [Measure: baseline → current (Δ=value)] for each relevant outcome
• Functional gains: [Specific ADL/mobility improvements with quantification]
• Remaining deficits: [Objective impairments and safety constraints limiting land progression]
• Rationale to continue aquatic vs transition: [Patient-specific justification]
• Updated goals: [Revised SMART goals with new targets]
• Revised request: [Frequency/week] x [Weeks]; [Total additional visits]; [Projected transition plan]