Certificate of Medical Necessity:
Physical Therapy and Occupational Therapy /
Fax or mail this
completed form / / For Pre-Service: Statewide Fax (877) 219-9448
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/Requesting Provider

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Name:

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BCBSF No:

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National Provider Identifier (NPI):

Contact Name:

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Phone:

Facility Information/
Location where services will be rendered /

Name:

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BCBSF No:

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National Provider Identifier (NPI):

Contact Name:

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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 toMedical 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 indicatesthe 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:

Certificate of Medical Necessity: Physical Therapy and Occupational Therapy1