VI. Requested services
Location of service delivery home outpatient hospital department physician’s ofce rehabilitation center therapist’s ofce
other (specify)
Date of initial evaluation Rehabilitation potential
Has (or will) the member use all of the visits allowed without prior authorization as part of the current treatment plan? yes no
If yes, estimate the number of additional visits that will be needed to achieve treatment goals.
How do your goals differ from the other therapy services currently being provided?
What other therapy services has the member received in the past 12 months?
Who will be responsible for the carryover of the home exercise program, if applicable?
If other than the member, is this person able to attend therapy sessions on a regular basis to obtain training? yes no
If yes, has the member been compliant with the home exercise program to date? yes no
Please indicate the type, frequency, duration, and length of visit per day that you are requesting.
Type Frequency per week Estimated duration Length of visit per day
(i.e., number of visits) (i.e., weeks, months)
Physical therapy
Occupational therapy
Speech/language therapy
VII. Medical necessity
Although most therapy can be viewed as benecial, MassHealth does not pay for therapy services unless they are medically necessary as specied
in 130 CMR 450.204, and meet the applicable MassHealth Guidelines for Medical Necessity.* Providers should address how the services
• provide specic, effective, and reasonable treatment of the member’s diagnosis and physical condition;
• are directly and specically related to an active treatment regimen;
• are of a level of complexity and sophistication that the judgment, knowledge, and skills of a licensed therapist are required;
• can achieve a specic diagnosis-related goal; and
• are reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life,
cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in illness or inrmity.
Provide a brief summary below of the medical necessity for the treatment you are proposing, including individual therapies and therapeutic activities.
This eld must be completed.
What are the objective measures you have used to chart progress toward the stated goals? This eld must be completed.
Important: You must attach a copy of the current physician’s referral for all requests in addition to completing this section. For rst requests, you
must also attach a copy of your initial evaluation. For subsequent requests, you must also attach a copy of the last two evaluations.
* Please refer to the MassHealth Guidelines for Medical Necessity Determination for Physical Therapy; the MassHealth Guidelines for Medical Necessity
Determination for Occupational Therapy; or the MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy, as
applicable, for additional information. These MassHealth guidelines are located on the MassHealth website at www.mass.gov/masshealth/guidelines.
Signature
Therapist’s name and title
Therapist’s signature Date
