Prior Authorization Request (Physical Therapy Services)

Request Type: [Initial / Continuation / Change in Frequency / Change in Setting]

Urgency: [Routine / Expedited — reason if expedited]

Date of Request: [Date]

Proposed Start Date: [Date]

Proposed End Date: [Date]

Payer: [Payer name, plan/product, prior auth reference number if resubmission]

Patient: [Full name, DOB, member ID, group ID]

Requesting Provider: [Name, credentials, NPI, fax/phone]

Rendering PT/Clinic: [Clinic name, address, NPI/TIN, PT name and credentials, contact info]

(Omit any section below that is not applicable. For continuation requests, ensure Functional Status, Prior Care and Response, and Plan of Care reflect updated response to treatment. Do not infer diagnosis codes, procedure codes, or objective values—leave placeholders for input if not provided.)

Requested Services

Setting/Site of Care	CPT/HCPCS Code(s) and Units	Frequency and Duration	Total Visits Requested	Visits Already Used (if continuation)	Last Authorized Period (if continuation)
[Setting/site of care]	[Code(s) with units]	[Frequency and duration]	[Total visits]	[Visits used]	[Start date – End date]

Primary ICD-10-CM Diagnosis Code(s): [Code(s) and descriptions]

Relevant Secondary Codes: [Codes affecting complexity or precautions]

(If exact CPT mix is not finalized, note that specific code distribution may vary based on response to treatment and list expected core service categories below.)

• [Expected core service categories]

Clinical Summary

• [Diagnosis and onset/exacerbation date]
• [Key functional limitations linked to activities/participation]
• [Headline objective measure 1]
• [Headline objective measure 2]
• [Headline objective measure 3]
• [Prior treatment(s) and response with timeframe]
• [Why skilled PT is required now]
• [Measurable goals with expected timeframe]
• [Risk if denied or delayed]

Relevant History and Precautions

(Include only information affecting PT plan, prognosis, or safety. If no precautions are reported, state "No precautions reported by referring provider.")

• [Relevant medical/surgical history]
• [Red flags, precautions, or contraindications]
• [Medications materially affecting therapy tolerance, fall risk, or symptom interpretation]

Functional Status

(Use Prior / Current / Goal structure when feasible. For continuation requests, document objective or functional change since last authorization, or explain slower-than-expected progress with rationale for ongoing skilled care.)

• Work/Role Participation: [Prior level] / [Current level] / [Goal level]
• ADLs/IADLs: [Prior level] / [Current level] / [Goal level]
• Mobility: [Prior level] / [Current level] / [Goal level]
• Assistive Device and Assistance Level: [Prior level] / [Current level] / [Goal level]
• Standardized Outcome Measure(s): [Instrument name, score, date, severity interpretation]
• Change Since Last Authorization: [Objective/functional change; setbacks or barriers; justification for continued skilled care] (Include for continuation requests)

Objective Findings

(Include only findings relevant to requested care. Provide units and test dates. For each impairment, briefly note functional impact.)

• Pain: [Rating with context]
• Range of Motion: [Key movement(s) with side-to-side comparison in degrees] — [Functional impact]
• Strength: [MMT or dynamometry values with method noted] — [Functional impact]
• Balance/Fall Risk: [Test name and score with units] — [Interpretation]
• Gait: [Speed, deviations, device, endurance] — [Safety/participation impact]
• Functional Performance Tests: [Test name with result and units] — [Relevance to goals]

Prior Care and Response

(Brief timeline format. Distinguish "not tried" from "unknown.")

• [Date — Prior medical management this episode]
• [Date range — Prior PT/rehab with frequency, visits, adherence, response]
• [Home exercise program status and adherence]
• [For continuation: interventions completed, what changed, what remains impaired]

Plan of Care

Long-Term Functional Goals:

• [In timeframe, patient will achieve measurable outcome tied to functional task (baseline → target)]
• [Additional long-term goal]

Short-Term Goals:

• [Short-term measurable step toward LTG]
• [Additional short-term goal]

Planned Skilled Interventions: [Intervention categories: therapeutic exercise, neuromuscular re-education, gait training, manual therapy, balance training, patient education, modalities if clinically justified]

Requested Frequency/Duration: [Amount, frequency, duration, and total visits with rationale for frequency]

Re-evaluation Cadence: [Schedule for progress checks/re-assessments]

Discharge Plan: [Criteria for discharge and plan for transition to self-management]

Medical Necessity Rationale

(Address medical necessity, need for skilled PT, improvement potential, and appropriateness of requested frequency/duration.)

• [Why the requested services are reasonable and necessary for this condition]
• [Why skilled PT is required and cannot be performed safely/effectively by unskilled personnel or home program alone]
• [Evidence supporting improvement potential]
• [Why the requested frequency/duration is appropriate]
• [Risk if delayed/denied]
• [Alignment with post-operative protocols or evidence-based guidelines, if applicable]

Attachments

(Check all that apply. Include document title, date, and author discipline.)

• [ ] PT Initial Evaluation — [date] — [author]
• [ ] Signed Plan of Care — [date] — [author]
• [ ] Most Recent Progress Note/Re-evaluation — [date] — [author] (For continuation)
• [ ] Prior Authorization History — [previous auth numbers and dates] (For continuation)
• [ ] Relevant Imaging or Operative Report — [date] — [author]
• [ ] Referring Provider Order — [date] — [author]
• [ ] Other: [document title] — [date] — [author]

Signature

Rendering PT: [Name, credentials, NPI, license number if required]

Signature: [Signature/attestation]

Date: [Date]

Clinic Contact for UM: [Name, phone, fax]