Prior Authorization Request (Music Therapy)

Request Type: [Initial / Continuation / Re-authorization / Expedited] (If expedited, include brief urgency reason)

Date of Request: [Date]

Requested Service Window: [Start date] through [End date]

Payer: [Payer name]; [Plan type]; [Policy name/number if known]

Prior Authorization Reference #: [Reference number / N/A - Initial Request]

Rendering Provider: [Name], [Credentials], NPI: [Number], License: [Number / N/A], Phone: [Number], Fax: [Number], Email: [Address]

Facility/Billing Entity: [Name], [NPI/TIN], [Address], Place of Service: [Setting]

Authorization Contact: [Name], Direct Phone: [Number]

Patient Name: [First Last]

DOB: [MM/DD/YYYY]

Member ID: [ID]

Group ID: [ID / N/A]

Address and Phone: [Address]; [Phone]

Benefit Category: [Behavioral health / Habilitative / Rehabilitative / Waiver service / Other / Coverage category to be confirmed]

Referring/Ordering Clinician: [Name], [Specialty], NPI: [Number], Contact: [Phone/Email] (Include if applicable)

Guardian/Consent Status: [Guardian name and relationship / Patient consents independently] (Include if patient is a minor or lacks capacity)

Clinical Summary

[Rationale for this request and current clinical context] (In 1–2 paragraphs: state primary diagnoses relevant to music therapy with approximate onset/duration; describe key functional impairments in concrete, observable terms; identify current setting and supports; specify the requested service and intended functional impact; note clinically supported risks if services are not authorized. Do not overstate risks.)

Diagnoses and Functional Impairments

• Primary Diagnosis: [Diagnosis name], [ICD-10 code]
• Relevant Comorbidities: [Comorbid conditions affecting treatment planning] (Only include those relevant to this request)
• Rule-Out Diagnoses: [Rule-out diagnoses if any] (Clearly label as rule-out)

Functional Deficits: (Use observable, quantifiable baselines with dates. Label each as observed or reported.)

• Communication: [Initiation, turn-taking, comprehension deficits with baseline frequency or assistance level; date] [observed / reported]
• Emotional/Behavioral Regulation: [Dysregulation frequency, severity, duration to baseline; triggers; date] [observed / reported]
• Cognitive/Attention: [Sustained attention duration, transition tolerance, working memory; date] [observed / reported]
• Motor/Sensory: [Motor planning, gait support, sensory responsivity; assistance level; date] [observed / reported]
• Social Participation: [Peer interaction, group tolerance, reciprocity; date] [observed / reported]
• ADL/School/Work Participation: [Attendance, task completion, self-care participation; date] [observed / reported]

Why Music Therapy Is Indicated

[Patient-specific rationale for music-based therapeutic methods and how they target non-musical functional outcomes] (Describe how individualized musical structure, cueing, pacing, and engagement mechanisms address identified barriers. Distinguish skilled therapy from recreational music by noting assessment-driven technique selection, objective progress monitoring, and ongoing clinical adjustment.)

Prior and Current Interventions: [Summary of PT, OT, SLP, psychotherapy, ABA, medications, school supports and patient's response—what improved, plateaued, and what barriers persist] (If music therapy was previously tried, summarize objective response and remaining gaps. If history is incomplete, note known elements and state that gaps do not change the currently documented impairments.)

Evaluation Summary

(Include for initial requests; abbreviate or omit for continuation requests if evaluation is already on file.)

• Evaluation Date: [MM/DD/YYYY]
• Evaluator: [Name], [Credential]
• Setting: [Location/context]
• Data Sources: [Patient report / Caregiver report / Chart review / Direct observation / Team input]

[Summary of clinically relevant findings across emotional/behavioral, cognitive/attention, communication/social, motor/sensory, and pertinent medical considerations] (Include musical responsiveness only as it informs treatment planning. Do not reproduce the full evaluation.)

Baseline Measures: (List standardized tools with scores/dates, or clearly defined observational baselines with frequency/duration/assistance level.)

• [Measure name] — Domain: [Domain]; Score/Value: [Value]; Date: [MM/DD/YYYY]; Interpretation: [Brief interpretation]
• [Observational metric] — Definition: [What is counted/measured]; Baseline: [Value]; Date: [MM/DD/YYYY]; Context: [Setting/task]

Requested Services

• Service: Music Therapy [CPT/HCPCS code if required by payer]
• Mode: [Individual / Group] (If group, note size)
• Session Length: [Minutes] per session
• Frequency: [Number] sessions per week
• Duration: [Number] total weeks
• Total Sessions/Units Requested: [Number]
• Delivery Method: [In-person / Telehealth]
• Place of Service: [Setting]

[Justification for requested frequency, duration, and total units] (If higher-than-typical intensity is requested, explain why lower frequency is insufficient. If a taper is planned, describe taper logic and decision points.)

Treatment Plan

[Brief overview tying interventions directly to functional goals]

• Approaches: [Therapeutic approaches pertinent to this patient, e.g., structured receptive listening for regulation, active instrument play for motor planning, rhythm-based cueing for functional movement, music-assisted communication practice, songwriting for emotional expression]
• Professional Skill Required: [Assessment-driven technique selection; moment-to-moment modification based on patient response; safety monitoring; objective data collection and analysis; interdisciplinary integration]
• Caregiver Training/Home Program: [Description / N/A]
• Interdisciplinary Coordination: [How goals align with other disciplines and plan for communicating progress]

Goals

(Organize by functional problem area. Include long-term goals for episode outcomes and short-term objectives with clear criteria, measurement methods, timeframe, generalization context, and expected support level. Include only highest-impact goals; attach full goal list if needed.)

• LTG 1 ([Functional domain]): Within [timeframe], patient will [specific functional behavior] to [target criteria] in [X/Y opportunities], measured by [method], in [context], with [support level]. Baseline: [current performance with date].
  • STG 1a: Within [timeframe], patient will [step behavior/skill] to [target criteria] in [X/Y opportunities], measured by [method].
  • STG 1b: Within [timeframe], patient will [step behavior/skill] to [target criteria], measured by [method].
• LTG 2 ([Functional domain]): Within [timeframe], patient will [specific functional behavior] to [target criteria], measured by [method], in [context], with [support level]. Baseline: [current performance with date].
  • STG 2a: Within [timeframe], patient will [step behavior/skill] to [target criteria], measured by [method].
  • STG 2b: Within [timeframe], patient will [generalize/maintain skill] to [target criteria] across [settings/partners], measured by [method].

Progress Summary

(Include for continuation/re-authorization requests only; omit for initial requests.)

• Service Dates: [Start] – [End]
• Visits Completed: [Number completed] of [Number authorized]
• Attendance Notes: [Pattern and barriers if relevant]

Goal-Area Updates: (For each goal area: document objective changes with measures; skilled adjustments and rationale; progress status; and why continued services remain necessary.)

• [Goal Area]:
  • Observed/Objective Data: [Measures, frequencies, durations, assistance levels with dates]
  • Patient/Caregiver Report: [Subjective outcomes, clearly labeled]
  • Clinical Adjustments: [What was modified and why]
  • Progress Status: [Adequate / Slow / Plateaued / Regressing] — [Reason]
  • Medical Necessity for Continued Care: [Justification, or rationale for discharge/step-down if appropriate]

Safety Considerations

(Include only if relevant safety concerns exist; otherwise omit this section entirely.)

[Precautions and mitigation strategies, e.g., seizure precautions, fall risk, elopement risk, sound sensitivity/hearing protection, infection control for shared instruments, behavioral safety plan] (If no known contraindications based on available history, state: "No known contraindications based on current information.")

Attachments

• [Document name] — [Date] — [Author/Source]
• [Document name] — [Date] — [Author/Source]

(Common attachments: music therapy evaluation report, current plan of care, progress summary, referring provider order, relevant medical records, standardized measure score sheets, provider credentials. If a required item is unavailable, note reason and expected date.)

Attestation and Contact

Music Therapist Signature: [Name]

Credentials: [Credentials]

Date: [MM/DD/YYYY]

Attestation: I attest that the information provided is accurate to the medical record, the requested services are medically/behaviorally necessary, and the goals are individualized and measurable.

Contact for Follow-up: Phone: [Number]; Fax: [Number]; Email: [Address]

Availability for Peer-to-Peer Review: [Days/Times]