Letter of Medical Necessity for Therapy
Client’s Name: ______________________________________________________ DOB: ___________________
Medical Diagnosis: ___________________________________________________ ICD 9 code: ______________
Please check all of the diagnoses below that apply:
Abnormality of Gait 781.2
Delayed Milestones 783.42
Mechanical Problems with Limbs V49.1
Hypotonia 728.9
Apraxia 784.69
Motor Problems with Limbs V49.2
Muscle Weakness 728.87
Feeding: Eating Disorder 307.59
Sensory Problems with Limbs V49.3
Lack of Coordination 781.3
Feeding Difficulties: Infant 783.3
Sensory Problems with Neck/ Trunk V48.5
Torticollis (congenital) 754.1
Plagiocephaly (skull) 754.0
Dysphagia: Oral 787.21
Dysphagia: Pharyngeal 787.23
Mechanical & Motor Problems w/ Neck/
Trunk V48.3
Difficulty In Walking 719.97
Fluency Disorder 315.35
Expressive Language Disorder 315.31
Articulation/ Phonological
Disorder 315.39
Mixed Receptive/Expressive Language
Disorder 315.32
Service Frequency Duration Therapist’s Signature
Physical Therapy
____ x/_____
____ mo
Occupational Therapy
____ x/_____
____ mo
Speech Therapy
____ x/_____
____ mo
Suggested Interventions:
Neuromuscular Re-Education (97112) Treatment of Speech / Language (92507)
Therapeutic Procedure (97110) Feeding / Swallowing / Oral-Motor (92526)
Therapeutic Activities (97530) Orthotics Management / Training (97760, 99762)
Gait Training (97116) ADLs / Self-Care including AAC device training (97535)
Manual Therapy Techniques (97140) Assistive Technology & Adaptive Equipment (97535)
Massage (97124) Group: OT, PT (97150) Speech (92508)
Evaluation/ Re-Evaluation Other: _________________________________________
An early intervention specialist (EIS) is providing specialized skills training (SST) &/or case management with
this client on a regular basis. A therapist (licensed professional of the healing arts- LPHA) will monitor services
for effectiveness in reducing functional limitations and achieving proper growth and development every six
months at a minimum. This monitoring may include evaluating/ re-evaluating the child and modifying the IFSP.
Therapy services provided by a licensed therapist are medically necessary for this client:
___________________________________________________________ ________________________
Physician Sign Here Date
Physician’s Name (Print):_______________________________________________________________________
Phone #:_________________ Fax #:_________________ Project TYKE phone: 281-237-6647 fax: 281-644-1846
This “Letter of Medical Necessity” is the last page of the therapy evaluation/ re-evaluation: No Yes: page ___