Prior Authorization Request (Equine Therapy)

Patient and Request Information

Patient Name: [Patient full name] DOB: [MM/DD/YYYY] Member ID: [Member ID] Phone: [Primary phone]

Parent/Guardian: [Name] Relationship: [Relationship] (Include only for pediatric patients or when legally required.)

Requesting Practice Name: [Practice name] Address: [Street, City, State, ZIP] Phone/Fax: [Phone] / [Fax] NPI: [NPI] Tax ID: [Tax ID]

Rendering Clinician: [Clinician name] Discipline: [PT / OT / SLP] Credentials: [Credentials] License #/State: [License number / State] NPI: [Clinician NPI]

Referring Provider: [Referring provider name] NPI: [Referring provider NPI] Contact: [Phone / Secure email / Fax]

Place of Service: [Clinic / Outpatient Facility / Other] — [Address] (Include notes on mounting area, indoor arena, or climate control only if directly relevant to safety feasibility.)

Authorization Request

(If payer uses portal fields, note "See portal; summarized here for clinical clarity.")

Requested Start Date	End Date / Approval Window	Total Visits / Units Requested	Session Length	Discipline(s)	Frequency (sessions/week)	Duration (weeks)
[MM/DD/YYYY]	[MM/DD/YYYY or approval window]	[# visits or units]	[Minutes per session]	[PT / OT / SLP]	[Sessions per week]	[# weeks]

Clinical Information

Diagnoses

• Medical Diagnosis: [Primary medical diagnosis] [ICD-10 code] (List relevant secondary diagnoses with ICD-10 codes as available.)
• Therapy/Functional Diagnosis: [Primary impairment or participation restriction] [ICD-10 code if applicable]

Relevant History

• Onset: [Onset date / Lifelong condition]
• Prior functional status/baseline: [Description of prior level of function relevant to goals]
• Current limitations/decline: [Description of current functional decline or limitations]
• Comorbidities and precautions: [Relevant comorbidities, precautions, weight-bearing status, seizure history, cardiopulmonary status, skin integrity, behavior/sensory considerations] (Include only if affecting necessity, safety, or intensity.)

Prior and Concurrent Care

• Prior therapy: [Type/discipline, dates, frequency, response/outcomes] (Include reasons for discontinuation or plateau if applicable.)
• Concurrent services: [Type/discipline, provider, frequency] (Document to demonstrate non-duplication.)
• Relevant equipment in use: [Devices such as AFOs, gait trainer, wheelchair, communication device] (Include only if affecting goals or safety.)
• History source and gaps: [Source of information; critical missing elements to confirm before mounted components]

Evaluation Summary

(Provide a payer-ready abstract, not an exhaustive narrative.)

Functional Limitations

• [Limitation #1 impacting home/school/work/community safety or access]
• [Limitation #2]
• [Limitation #3]
• [Additional limitations as needed] (Include 2–5 concrete participation restrictions.)

Objective Findings

(Include only findings that support skilled need. Never insert templated "normal" findings; use "Not assessed—[reason]" if examination was limited.)

• Neuromotor: [Tone, motor control, balance reactions, coordination]
• Musculoskeletal: [ROM, strength, endurance, posture/alignment]
• Mobility: [Transfers, gait quality, assist level, device use, endurance]
• Sensory/Behavioral/Cognitive: [Attention, communication, sensory processing, behavioral regulation] (Include only if relevant to safety or participation.)

Baseline Functional Status

(Document 3–8 anchor tasks with standardized assist descriptors.)

• [Task]: [Independent / Supervision / Min Assist / Mod Assist / Max Assist / Dependent]; [Device if applicable]
• [Task]: [Assist level]; [Device]
• [Task]: [Distance/time if applicable]; [Assist level]; [Device]
• [Additional tasks as needed]

Clinical Complexity

(Include 1–3 factors driving skilled need.)

• [Medical complexity and safety risks requiring ongoing clinical decision-making]
• [Medication interactions or physiologic instability affecting treatment tolerance]
• [Behavioral/sensory needs or specialized handling requirements]

Outcome Measures

(Select measures aligned with primary deficit domains. Never use placeholder scores; mark as "Not obtained—[reason]" with plan to obtain.)

Measure Name	Date Administered	Baseline Score + Interpretation	Reassessment Interval	Goal Threshold (MCID/MDC if known)
[Measure name]	[MM/DD/YYYY]	[Score + interpretation]	[Reassessment interval]	[Threshold / MCID / MDC]
[Additional measures as needed]

Skilled Intervention Plan

(Organize by problem: Problem statement → Skilled interventions → Functional intent. Rank problems by severity.)

Problem 1: [Primary impairment/participation restriction]

• Skilled Interventions: [Interventions with graded approach, cueing strategies, progression parameters]
• Functional Intent: [Concrete function to be improved]

Problem 2: [Secondary impairment/participation restriction]

• Skilled Interventions: [Interventions tailored to problem]
• Functional Intent: [Functional target]

(Add additional problems as applicable.)

Equine Movement Integration

• Therapy Modality: [Physical Therapy / Occupational Therapy / Speech-Language Pathology] incorporating equine movement as a treatment tool (Equine movement is not a separate service.)
• Mounted Component: [Targeted impairments addressed during mounted portion; handling strategies; progression criteria]
• Off-Horse Clinical Component: [Carryover activities, strengthening, functional task training, caregiver education/home program]
• Patient-Specific Rationale: [Link equine movement characteristics to this patient's measured deficits and functional goals] (Avoid generalized wellness statements.)

Anticipated CPT Code Families

[Therapeutic exercise, Neuromuscular re-education, Gait training, Therapeutic activities, Manual therapy, Self-care/ADL training, SLP treatment codes as applicable] (Codes listed are anticipated families; final coding reflects services actually performed.)

Treatment Dose

• Type: [PT / OT / SLP]
• Frequency: [Sessions per week]
• Duration: [Total weeks or visits in authorization period]
• Session Length: [Minutes per session]
• Taper Plan: [Progression to lower frequency or transition criteria] (Include if clinically appropriate.)

Goals

(Include measurable, time-bound functional goals tied to participation and objective measures.)

• [Timeframe]: [Patient] will [functional task] [distance/accuracy/quality] with [device if any] at [assist level] to [participation outcome].
• [Timeframe]: Improve [outcome measure] from [baseline] to [target/MCID/MDC] to support [functional participation].
• [Additional goals as needed]

Medical Necessity Statement

[Structured narrative of 5–10 sentences addressing: (1) Key functional limitations requiring intervention; (2) Why skilled therapy is required including clinical reasoning, ongoing assessment needs, and safety risks; (3) Why requested frequency and duration are reasonable; (4) Why equine movement integration is appropriate for this patient's specific impairments; (5) Expected measurable gains within authorization window tied to outcome measures; (6) Discharge or transition criteria.]

Equine Session Safety Plan

Contraindication Screening

• Screening completed: [Yes / No]
• Flagged conditions requiring clearance: [Cervical instability risk / Seizure history / Acute exacerbation / Unstable joints or spine / Open wounds / Indwelling lines or catheters / Other]
• For each flagged condition: Status: [Cleared / Pending]; Source of clearance: [Provider name/discipline or documentation]; Mitigation: [Plan]

(If any condition is pending clearance, mounted components will not occur until cleared. Document interim clinic-based care plan.)

Fall Risk Management

• Helmet: [ASTM/SEI type]; [Fit confirmed]; [Sensory tolerance plan if applicable]
• Patient handling/guarding: [Gait belt / Supportive vest / None] — Rationale: [Rationale]
• Mount/Dismount: [Block / Ramp / Lift]; [Minimum staff and roles]; [Side-walkers as needed]
• Patient-specific triggers and de-escalation: [Known triggers]; [Early warning signs]; [De-escalation/stop criteria]

Treatment Team

• Minimum team: Licensed therapist (team lead), horse handler, [0–2] side-walkers/aides as needed
• Roles: Therapist—clinical decision-making, patient handling, progression; Horse handler—equine control per therapist direction; Side-walkers—patient guarding and cueing; All—emergency response per protocol

Emergency Preparedness

• Emergency dismount: [Procedure trained and practiced; activation criteria]
• First aid/CPR: [On-site availability]; [AED if present]
• Incident response: [Documentation process]; [EMS activation criteria]; [Guardian/PCP notification process]

Environmental Safety

• Weather thresholds: [Heat index limit]; [Cold/windchill limit]; [Lightning policy]
• Allergy/asthma plan: [Rescue medication availability if prescribed]; [Trigger avoidance]
• Medication side effects relevant to session: [Photosensitivity / Orthostasis / Sedation / Other]

Attachments

• Evaluation report: [Attached / Not attached / Available upon request]
• Plan of care and goals: [Attached / Not attached / Available upon request]
• Physician order/referral: [Attached / Not attached / Available upon request]
• Medical clearance letters: [Attached / Not attached / Available upon request / N/A]
• Prior therapy notes: [Attached / Not attached / Available upon request / N/A]
• Outcome measure score sheets: [Attached / Not attached / Available upon request]

Attestation and Contact

I attest that the requested services are within my professional scope of practice, medically necessary based on the above clinical findings, and will be delivered as skilled [Physical Therapy / Occupational Therapy / Speech-Language Pathology] with equine movement utilized as a treatment tool within the plan of care. Final CPT code selection will reflect the skilled interventions actually performed during each session.

Rendering Therapist Signature: ______________________ Credentials: [Credentials] Date: [MM/DD/YYYY]

Contact for Peer-to-Peer Review: [Clinician name] Phone: [Direct line] Best Time: [Days/Hours]