CMN_Physical_Therapy_and_Occupational_Therapy_Final



|Certificate of Medical Necessity: |[pic] |

|Physical Therapy and Occupational Therapy | |

| |

|Fax or mail this | |For Pre-Service: Statewide Fax (877) 219-9448 |

|completed form | |For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614 |

| | |For Post-Service Claims: |

| | |Florida Blue |

| | |P.O. Box 1798 |

| | |Jacksonville, FL 32231-0014 |

|Section A |

|Physician Information/ |Name:       |BCBSF No:       |National Provider Identifier (NPI):       |

|Requesting Provider | | | |

| |Contact Name:       |Phone:       |

|Facility Information/ |Name:       |BCBSF No:       |National Provider Identifier (NPI):       |

|Location where services will be| | | |

|rendered | | | |

| |Contact Name:       |Phone:       |

|Member Information |Last Name:       |First Name:       |

| |Member/Contract Number (alpha and numeric):       |Date of Birth:       |

|Procedure Information |Procedure Code(s):       |Procedure Description:       |

| |Units (if applicable):       |

| |Indicate reason for over the allowed amount of units: |

| |      |

| |Diagnosis code(s):       |Diagnosis Description:      |

| |Date of Service/Tentative Date:       |

|Section B |

|Medical Necessity: For detailed information on physical therapy or occupational therapy including the criteria that meet the definition of medical necessity, |

|visit the Florida Blue Medical Coverage Guideline website at . Refer to Medical Coverage Guideline 01-97000-01, Physical Therapy and |

|Occupational Therapy. For Medicare visit and refer to National Coverage Guidelines 150.1, 150.5, 150.8, 240.3 and Local Coverage Determination |

|L29116. |

|Section C |

Check all boxes and complete all entries that apply:

| Yes | No |Is the member receiving any of the following services? |

| | |Check all that apply: |

| | | |Augmented soft tissue mobilization |

| | | |Dry hydrotherapy |

| | | |Dynamic method of kinetic stimulation [(MEDEK therapy or Cuevas Medek Exercises (CME) |

| | | |Electromyography |

| | | |Interactive metronome program |

| | | |Kinesio taping |

| | | |Skeletal analysis systems |

| | | |Unattended vibromassage therapy |

| | | |Hands-free ultrasound (low frequency sound, or infrasound) |

| | | |Equestrian therapy (S8940) |

| | | |Hivamat therapy (deep oscillation therapy) |

| Yes | No |Is the member’s condition or complexity such that it requires the services be performed by or under the direct supervision of a |

| | |qualified physical or occupational therapist? |

| Yes | No |Are the services in accordance with a a physician directed written treatment plan? |

| Yes | No |Is member’s history and diagnosis included in the plan? |

| Yes | No |Does the treatmentplan contain stated and attainable short and long term goalswhich can be objectively measured? |

| Yes | No |Does the treatment plan include specific procedures, techniques, interventions and/or modalities, including frequency and duration, |

| | |that are specific to and based on the individual’s diagnosis and prognosis? |

| | |If Yes, describe requency and duration:       |

| | |If Yes, describe modalities:       |

| Yes | No |Are the services necessary to improve, restore or develop physical functions in members who have a functional deficit? |

| Yes | No |Is the initial physical or occupational therapy evaluation performed by a qualified provider of physical or occupational therapy? |

| Yes | No |Is this request for physical therapy and occupational therapy? |

| | | Yes | No |Are there documented separate treatment plans and goals for each therapy? |

| Yes | No |Is this request for a continuation of physical therapy or occupational therapy or both services? |

| | | Yes | No |Is there an updated treatment plan for continuation of therapy that has been recertified by the physician |

| | | | |within the past 90 days? |

| | | Yes | No |Are there changes to the modalities, frequency or duration of the plan? |

| | | | |If Yes, describe:       |

| | | Yes | No |Is there documentation of improvement of the member's level of functioning based upon objective testing? |

| | | | |If Yes, describe:       |

|Autism Spectrum Disorders |

| Yes | No |Is the physical/occupational therapy being rendered for the treatment of comorbidities of Autism Spectrum Disorder (ASD)? |

| | | Yes | No |Is the therapy beingrendered for the treatment of comorbiditiesof ASD? |

| | | Yes | No |Are the therapy services being rendered in accordance with the treatment plan as prescribed by the |

| | | | |treating physician and updated no less than every six (6) months? |

| | | Yes | No |Does the therapy treatment plan contain the diagnosis, the proposed treatment type, frequency, and |

| | | | |duration of the treatment with the outcomes stated as goals? |

| | | Yes | No |Does the therapy treatment plan include the frequency of update to the treatment plan and the treating |

| | | | |physician signature? |

|Massage Therapy |

| Yes | No |Is there documentation on file indicating that 97124 or 97140 are specifically prescribed bythe attending physician as medically |

| | |necessary? |

| Yes | No |Does the attending physician's prescription specify the number of treatments? |

|Manual Lymph Drainage |

| Yes | No |Is this the first course of treatment for the diagnosis of lymphedema? |

| Yes | No |Can the member be instructed in a home program for the treatment of lymphedema? |

| Yes | No |Is there a caregiver that can assist the member in continuing home lymphedema therapy? |

|Aquatic Therapy |

| Yes | No |Is this duplicative to the land based therapy services? |

|Physical performance tests and measurements (make this one sentence |

| Yes | No |Is the physical performance test being rendered for any of these reasons; evaluating a patient's physical performance, determining |

| | |function of one or more body areas or measuring any aspect ofphysical performance including functional capacity evaluations? |

| Yes | No |Has the member been diagnosed with cerebral palsy? |

| Yes | No |Is this the preoperative or postoperative evaluation for gait analysis of musculoskeletal function? |

|Section D – Medicare Members |

Check all boxes that apply:

| Yes | No |Are the services provided by a qualified licensed professional (physician, physical therapist, occupational therapist) as an integral|

| | |part of a treatment plan? |

| Yes | No |Is this a request for additional therapy services for the same condition? |

| Yes | No |If this is a request for continuation of services, is there documentation that indicates the member's condition has improved? |

| | |Specify how condition/function has improved:       |

Additional Comments:

|      |

|I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical |

|Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation |

|necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a |

|guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan |

|benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to |

|comply with such request may be a basis for the denial of a claim associated with such services. |

|Ordering Physician’s Signature: |Date:       |

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