Prior Authorization Request (DMEPOS Orthoses/Prosthetics)

Prior Authorization Request Summary — DMEPOS Orthoses and/or Prosthetics

Patient Information Patient Name: [Patient full name] DOB: [MM/DD/YYYY] Member ID/MBI: [Member ID or MBI / NOT PROVIDED] Address: [Street, City, State ZIP] Phone: [Patient phone] Place of Service: [home / outpatient clinic / inpatient / SNF / other]

Request / Payer / Supplier Request Date: [MM/DD/YYYY] [v1 / v2 / v3] (Include version if resubmission) Request Type: [Initial / Resubmission / Expedited] Expedited Rationale: [One sentence stating why delay jeopardizes health or function] (Include only if expedited; otherwise omit) Payer: [Payer name]; [Medicare FFS / Medicare Advantage / Medicaid / Commercial] Ordering Practitioner: [Name, credentials, NPI, phone/fax/email] Supplier: [Supplier name, NPI/PTAN, phone/fax/email]

Requested DMEPOS Items (HCPCS)

(Itemize base devices and separately billed accessories as separate rows. Do not infer codes, modifiers, quantities, length of need, or laterality; use placeholders if not specified. Group items by body region using subheader rows when applicable.)

HCPCS Code	Description	Modifiers	Qty/Units	Length of Need	Linked Diagnoses (ICD-10)	Notes
[Body Region Subheader — e.g., Spinal / Upper Limb / Lower Limb] (Use as needed)
[HCPCS code / PENDING]	[Base device description — include laterality and amputation level if applicable]	[Modifiers / PENDING]	[Quantity / PENDING]	[Duration / PENDING]	[ICD-10 codes]	PA required: [Y / N / Unknown]; F2F/WOPD required: [Y / N / Unknown]; Upgrade: [Y / N]
[HCPCS code / PENDING]	[Accessory/component description]	[Modifiers / PENDING]	[Quantity / PENDING]	[Duration / PENDING]	[ICD-10 codes]	PA required: [Y / N / Unknown]; F2F/WOPD required: [Y / N / Unknown]; Upgrade: [Y / N]
(Add additional rows for each requested item)

Diagnoses / Clinical Indications

(List relevant diagnoses in descending order of relevance. Include brief context and key dates. Omit diagnoses that do not affect coverage or medical necessity.)

• [ICD-10]: [Diagnosis name] — [Brief clinical context; key date(s): onset, injury, surgery, last device, deterioration]
• [ICD-10]: [Diagnosis name] — [Brief clinical context; key date(s)]
• (Add additional diagnoses as applicable)

Medical Necessity Overview

[5–7 sentence summary integrating: current functional limitation/problem; requested device category (reference HCPCS table); top 2–4 objective findings; rationale for requested level versus lower-intensity alternatives; and top 2 functional goals. All claims must be traceable to cited source documents.]

Medical Necessity Narrative

(Organize by device or problem group. Repeat the following subsection for each device/problem requested.)

[Device/Problem Group — e.g., Spinal Orthosis / Knee Orthosis / AFO / Lower-Limb Prosthesis]

Clinical Indication: [Condition being treated/prevented/rehabilitated; severity; course (acute/subacute/chronic); trajectory (worsening/stable)]. (Cite source: date, author, encounter type.)

Functional Impact: [Baseline limitations: ambulation distance, transfers, stairs, standing tolerance, ADLs, work tasks; safety concerns: falls, near-falls, instability, skin risks]. (Cite sources and dates.)

Prior Interventions: [Therapies attempted (PT/OT, medications, injections, prior bracing/prosthesis, activity modification) and response (improved/not improved/intolerant)]. (Cite dates and authors.)

Rationale for Requested Device: [Specific device features required; why lower-cost/level options are insufficient or contraindicated; note if upgrade and why necessary]. (Tie to objective findings and functional goals.)

Expected Outcomes and Risk of Non-Authorization: [Expected benefits: pain reduction, stabilization, healing, fall reduction, improved function. Risks if denied: continued falls, delayed healing, worsening deformity, functional decline].

(Repeat above subsection for each additional device/problem group.)

Objective Clinical Findings

(Provide dated, source-cited bullet points. Only include findings present in supplied documentation. Omit subheaders with no applicable data; note "Imaging: none provided" if imaging expected but absent.)

Musculoskeletal

• [MM/DD/YYYY] — [ROM, strength grades, ligament laxity, edema, pain with motion] (Source: [Author, encounter type])

Neurologic

• [MM/DD/YYYY] — [Sensory deficits, motor findings, reflexes, proprioception, tone] (Source: [Author, encounter type])

Gait/Balance

• [MM/DD/YYYY] — [Device use, antalgia, endurance, assistance level, stairs/terrain; standardized measures (TUG, 6MWT, Berg, gait speed); fall count] (Source: [Author])

Skin / Residual Limb

• [MM/DD/YYYY] — [Pressure areas, wounds, limb length/shape/volume, skin tolerance, contractures] (Source: [Author])

Imaging / Tests

• [MM/DD/YYYY] — [Key result and relevance] (Source: [Report/Author])
• [Imaging: none provided] (Include only if imaging expected but not supplied)

Anthropometrics / Measurements

• [MM/DD/YYYY] — [Limb circumferences, alignment, sizing notes, weight/height if relevant] (Source: [Author])

Functional Status / Mobility Classification

(Include when requesting prosthetic knees/feet/ankles, higher-end components, or when payer policy references functional levels; otherwise omit this section.)

• Current Ambulatory Status: [non-ambulatory / household / limited community / community / high impact]; [assistive device use]; [supervision/assistance needs]
• Terrain/Tasks: [Capability on stairs, hills, uneven terrain, curbs]
• Functional Level Classification: [Payer-specific classification tied to observed function and expected potential] (Cite supporting findings and dates.)
• Rehabilitation Plan: [Therapy plan and anticipated progression]

Functional Goals

(List 2–5 specific, measurable goals. Include at least one safety-related and one ADL-related goal when relevant. If goals not documented in source records, state: "Goals: NOT DOCUMENTED – REQUESTING CLINICIAN INPUT.")

• Goal 1: [Goal statement]. Baseline: [current status]. Target: [measurable target]. Timeframe: [weeks/months]. Measure: [metric].
• Goal 2 (Safety): [Fall reduction/stability goal]. Baseline: [current status]. Target: [measurable target]. Timeframe: [weeks/months]. Measure: [metric].
• Goal 3 (ADL): [Transfers, bathing, toileting, community access]. Baseline: [current status]. Target: [measurable target]. Timeframe: [weeks/months]. Measure: [metric].
• (Add additional goals as needed, maximum 5 total)

Implementation Plan

(May be omitted for simple off-the-shelf brace requests.)

• Process: Evaluation → Casting/Scan → Fabrication → Fitting → Delivery → Follow-up
• Training: [Don/doff training, skin checks, gait training, wear schedule, maintenance education]
• Anticipated Delivery Window: [Date range], contingent on authorization
• Follow-up Intervals: [Timeframes and responsible provider(s)]

Documentation Cross-Check

(Flag any submission-blocking deficiencies explicitly.)

• Order: [SWO / WOPD]. Completeness: Patient ID [Y/N], Item description [Y/N], Quantity [Y/N], Practitioner name/NPI [Y/N], Order date [Y/N], Signature/date [Y/N]. Status: [complete / incomplete / missing elements].
• Face-to-Face Encounter: Required? [Y / N / Unknown]. Date: [MM/DD/YYYY]. Author: [Name, credentials]. Modality: [in-person / telehealth]. Within required timeframe: [Y / N].
• Prior Authorization Requirement: [Y / N / Unknown]. Source: [payer portal / policy list / benefits verification]; Reference: [number/policy ID if available].
• If Resubmission: [Summary of corrections/additions compared to prior submission].

Attachments Checklist

Document Name	Date Range	Author/Clinic	Included	Notes
Signed Order (SWO/WOPD)	[MM/DD/YYYY]	[Ordering practitioner]	[Y / N]	[Notes]
Face-to-Face Encounter Note	[MM/DD/YYYY]	[Practitioner]	[Y / N]	[Within required timeframe Y/N]
Treating Practitioner Progress Notes	[Date range]	[Clinic/Author]	[Y / N]	[Notes]
Orthotist/Prosthetist Evaluation & Measurements	[MM/DD/YYYY]	[O&P Supplier]	[Y / N]	[Notes]
PT/OT Therapy Notes	[Date range]	[Therapist/Clinic]	[Y / N]	[Notes]
Imaging / Test Reports	[Date range]	[Facility/Author]	[Y / N]	[Key findings]
Operative Reports / Discharge Summaries	[Date range]	[Facility/Surgeon]	[Y / N]	[Notes]
Prior Device History	[Date range]	[Supplier/Clinic]	[Y / N]	[Dispense records, serial numbers]
Payer-Specific Forms	[MM/DD/YYYY]	[Preparer]	[Y / N]	[Notes]
(Add additional rows as needed)

Missing/Requested Documents: [List any expected documents not yet obtained; include request date and status]

Attestation and Contact

Prepared by: [Name, role/title]

Contact: [Phone] | [Fax] | [Email]

Statement: This summary reflects the attached medical record documentation. All sources are identified by date and author.