Prior Authorization Request (Biofeedback Therapy)

Prior Authorization Request – Biofeedback Therapy (Letter of Medical Necessity)

(Keep this document concise and decision-focused. Prioritize quantifiable data and clearly labeled bullets so reviewers can locate key items within 1–2 pages.)

Patient and Payer Information

Date of Request: [Date of request]
Urgency: [routine / expedited] (If expedited, include specific medical reason)
Patient: [Patient full name], DOB: [Date of birth]
Member ID / Group Number: [Member ID] / [Group number]
Payer: [Payer name], Plan type: [commercial / Medicaid MCO / Medicare Advantage / other]
Type of Request: [initial / continuation]
Prior Authorization Reference Number: [Reference number] (Include only for continuation requests)
Requesting Clinic: [Clinic name], [Address], [Phone] / [Fax], NPI: [Clinic NPI]

Providers

Ordering/Referring Clinician: [Clinician name, credentials, NPI]; Referral date: [Referral date] (Attach order if required by payer)
Rendering Provider: [Provider name, credentials], [PT / OT / psychology / physician], NPI: [Provider NPI]
Contact for Clinical Questions: [Contact name]; Direct phone: [Phone number]; Best times for peer-to-peer: [Availability]

Requested Services – Decision Capsule

• Service: [Specific biofeedback service and target system, e.g., pelvic floor EMG biofeedback, anorectal biofeedback, headache behavioral biofeedback]
• Setting: [office / outpatient facility]
• Diagnosis/Indication: [Diagnosis with ICD-10 code if applicable]
• Authorization Window: [Requested start date] to [End date]
• Frequency: [Frequency and duration, e.g., 1 visit/week × 6 weeks]
• Total Visits Requested: [Number of visits]
• Re-evaluation Timing: [By visit number and/or calendar interval]
• Billing Codes: [CPT/HCPCS codes with units per visit] (Include only if clinic documents codes in notes; otherwise provide on payer form)

Key Medical Necessity Snapshot

• Diagnosis & baseline severity: [Concise summary with quantified metrics]
• Failed conservative care: [Top 1–3 prior treatments with brief outcomes]
• Planned outcome measures: [Named measures/diaries and timing for reassessment]

(Keep to 3–5 bullets; avoid repeating details verbatim from later sections.)

Clinical Indication

[One-line statement naming condition and why treatment is needed now]

[Symptom details: onset, duration, current severity quantified where possible, triggers/relievers, functional impact on work/daily activities/sleep/continence confidence/social participation] (Include only information explicitly documented.)

[Pertinent comorbidities or risk factors affecting treatment plan or necessity determination] (Include only if relevant.)

[Red flags or contraindications relevant to safe provision or indicating alternative pathway] (Include only if applicable.)

Conservative Management and Prior Treatments

• [Treatment name]: [Start date] to [End date or total duration]; Adherence: [good / fair / poor / unknown]; Objective response: [Quantified effect]; Outcome: [stopped / ongoing / insufficient] because [Reason]
• [Treatment name]: [Dates]; Adherence: [Level]; Objective response: [Effect]; Outcome: [Result and reason]

[If no conservative care attempted, document contraindication/urgency/access barrier and clinician rationale] (Include only if applicable. Do not infer failed treatments—list only trials explicitly documented.)

Objective Baseline Data

• Exam/Test Finding: [Objective physiologic or physical finding] on [Date of exam]
• Patient-Reported/Diary Measure: [Measure name] = [Score or counts] collected [Date or date range]
• [Additional baseline metrics relevant to indication] (For pelvic floor/urinary: voiding diary frequency, urgency episodes, incontinence episodes, nocturia, pad use, pelvic floor strength/endurance/coordination/tone. For anorectal: stool frequency, straining severity, incomplete evacuation, Bristol stool form, manometry/balloon expulsion. For headache: headache days/month, average duration, acute medication use, disability scores.)

[Baseline measure not yet obtained because [Reason]. Will be obtained at initial evaluation on [Date] and used to track progress.] (Use only if baseline data unavailable at time of request.)

Medical Necessity Rationale

[Brief summary: diagnosis, key supporting findings, and why biofeedback is the appropriate next step now]

• Skilled biofeedback needed because: [Supervised learning/cueing/re-training requirements that cannot be replicated by unsupervised home exercise]
• Alternatives insufficient because: [Reference to conservative management outcomes above]
• Frequency/duration reasonable because: [Rationale related to expected learning curve, physiologic re-training timeline, and monitoring needs]
• Measurable improvement expected because: [Connection between baseline metrics and expected change]
• Setting justification: [Why office/facility delivery is necessary vs. home per payer policy] (Include only if relevant to payer requirements.)

Treatment Plan

Planned Interventions: [Biofeedback modality and training focus, e.g., recruitment, relaxation/down-training, coordination, endurance]; [Education components: home program, habit training, trigger management]; [Adjunctive therapies included in this request]

Dose: [Visit frequency]; [Anticipated session length]; [Total visits requested]; [Taper plan if applicable, e.g., weekly then biweekly]

Re-evaluation Plan: [Timing by visit number and/or calendar interval]; Triggers for earlier re-evaluation: [plateau / symptom worsening / adverse effects / inability to participate]; Documentation to be produced: [progress report / updated plan / continuation or termination recommendation]

Continuation Criteria: [Objective progress toward goals, quantified]; [Ongoing need for skilled cueing/training]; [Updated plan changes based on reassessment]

Goals and Outcome Measures

• Goal 1: [Specific function or behavior]; Measure: [Measure name]; Baseline: [Value or "to be obtained at evaluation"]; Target: [Value or threshold of meaningful change]; By: [Visit number or date]
• Goal 2: [Function or behavior]; Measure: [Measure name]; Baseline: [Value]; Target: [Value]; By: [Visit number or date]
• Goal 3: [Function or behavior]; Measure: [Measure name]; Baseline: [Value]; Target: [Value]; By: [Visit number or date]

(Each goal should be specific, measurable, achievable, relevant, and time-bound. Align measures with those in Objective Baseline Data.)

Attachments

• [Initial evaluation or most recent clinical note supporting medical necessity]
• [Plan of care]
• [Relevant test reports, e.g., voiding diaries, manometry summaries]
• [Documentation of failed conservative management]
• [Payer-required prior authorization forms]
• [Other supporting documents]

[Attachment not available: [Document type] because [Reason]] (Include for any commonly required document not attached.)

Attestation

Clinician Signature: ___________________________

Printed Name and Credentials: [Clinician name and credentials]

Date: [Signature date]

I attest the above is accurate and medically necessary; services will be delivered as described and re-evaluated at the stated interval. (Optional attestation statement.)