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Run: Therapy Medical Necessity Justification

Therapy Medical Necessity Justification template for documenting functional limits, objective progress, and the skilled rationale for continued therapy. Use ...

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Submission Context

Submission Date (required)

Patient Identifier (required)

Use the internal medical record number or other approved identifier. Do not enter unnecessary PII.

Therapy Discipline (required)

Justification Type (required)

Episode Start Date

Functional Limitations

Primary Functional Limitations (required)

Functional Impact Summary (required)

Describe how the limitation affects daily function, safety, independence, or participation.

Baseline or Current Status (required)

Summarize the current level of function using objective measures, assistance level, or observable performance.

Safety Risk Present? (required)

Safety Risk Details

Explain fall risk, aspiration risk, poor judgment, pain-related guarding, or other safety concerns.

Objective Progress and Response to Treatment

Objective Measures (required)

Include relevant scores, range, strength, gait, task performance, or other measurable findings.

Progress Since Last Review (required)

Describe changes in function, tolerance, independence, or symptom control since the prior review.

Response to Skilled Intervention (required)

Explain why the intervention requires clinical judgment, cueing, progression, or modification by a skilled therapist.

Barriers to Progress

Barrier Details

Provide context for any selected barriers and how they affect prognosis or treatment response.

Medical Necessity Rationale

Skilled Services Still Needed (required)

Medical Necessity Statement (required)

Explain why the patient requires skilled therapy rather than independent home exercise or unskilled support.

Risk If Therapy Stops (required)

Describe likely decline, plateau, safety risk, loss of function, or increased caregiver burden if services end.

Expected Outcome With Continued Therapy (required)

State the anticipated functional gains, maintenance goals, or discharge readiness criteria.

Plan, Consent, and Attestation

Recommended Treatment Frequency (required)

Enter the planned visits per week and duration, such as '2x/week for 4 weeks'.

Does the Plan of Care Need Updating? (required)

Plan Update Details

Describe any changes to goals, frequency, duration, or intervention approach.

Consent to Document Patient Identifiers (required)

Collect only the minimum necessary PII and use approved identifiers where possible.

Yes No N/A

Clinician Name (required)

Clinician Credentials (required)

Attestation (required)

Signature confirms the documentation is accurate and supports the audit trail.

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