MUST BE SUBMITTED BY PHONE

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Neurodevelopmental Program: PT Therapy Clinical Worksheet Required for all Neurodevelopmental Conditions Please use this fax form for NON-URGENT requests only.

1 Neurodevelopmental Program: PT Therapy Clinical Worksheet Required for all Neurodevelopmental Conditions Please use this fax form for NON-URGENT requests only. Failure to provide all relevant information may delay the determination. Phone and fax numbers may be found on evicore.com under the Guidelines and Forms section. You may also log into the provider portal located on the site to submit an authorization request. URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE uth Number (If Continued Care): Date of Submission: wing demographic sections contain information necessary to initiate a fax request. When submitting by fax, low is required. When submitting online, you will only be prompted to provide the information necessary to propriate patient and provider for this request. lan/insurer: MI: Last Name: DOB (mm/dd/yyyy): Gender: Male Female Apt #: State: Zip: Cell Phone: Primary: Home Cell Last Name: : TIN: NPI: Physician Fax: State: Ext: Suite #: Zip: Description Code Description s Request: most appropriate): New condition not previously treated Same/previous condition nt evaluation: Date of onset of CONDITION: indings: fabricating a splint/orthotic or developing a home exercise program only? Yes No Please answer the following for patients residing in Florida only te duty nursing) service in the home Reside in a SNF (skilled nursing facility) a PPEC (prescribed pediatric extended care center Continues on Next Page vicore.com Revised corepath MSK Neurodevelopmental PT Form Page 1 of 5

2 CLINICAL INFORMATION cal Condition: (Choose only one) Disorder Torticollis ADHD/Sensory Processing Disorder isorder or Delay (e.g. coordination, delayed milestones, etc.) Other neurologic/neuromuscular disorder (Spina Bifida, genetic, post-surgical ) ems to be addressed in this authorization request: (not required for torticollis) Range of Motion Strength Gross Motor Skills nce Posture Visual Motor/Perceptual Skills e Other clinical problem rgery in the past 2 months OR is expected to have surgery in the next 2 months? Yes No TREATMENT REQUEST all requests. Enter 0 if unknown. If request is for one visit every 2 weeks, please enter.5 in Visits Requested. er of: WEEK: Number of Units Requested per Visit: Number of Weeks: nter 0 if no prior visits this year. Number of visits to date this calendar year: ION RESULTS - Torticollis otation on affected side* Patient age (IN MONTHS) when treatment started 5 degrees, enter 75. This is considered a deficit of 15 degrees.) RDIZED TEST RESULTS. (Not required for torticollis -- skip to Additional Information) is required every 6-12 months. Standardized scores must be reported with each request. (Age reening tools do not meet the requirement for standardized testing.) Please enter only the relevant or posite scores. Please select from list in appendix 1. performed, please enter reason below: tly regulated Unable to tolerate testing Other reason e (1): Standardized Score Test Name (2): Standardized Score was performed. (NOTE: test should be within the past year to be considered valid) djusted age (in months): If not applicable, leave blank. Continues on Next Page vicore.com Revised corepath MSK Neurodevelopmental PT Form Page 2 of 5

3 H CEREBRAL PALSY. Gross Motor Function Assessment. Please select description that best fits. See appendix 2 for explanation of levels, if needed irthday): No limitations. Able to walk if old enough rawl. May pull to standing and cruise. port in sitting. Able to roll and creep. but requires trunk support to sit. May be able to roll to prone. ead and trunk in prone and sitting. Requires assistance to roll. irthday): No assistance required. Walking is preferred method of mobility. but may have difficulty with balance. May use assistive device for walking. quires some assistance. Creeping/Crawling is preferred means of mobility. May walk with assistance. port required for sitting. Unable to walk. limited, including head and trunk control. irthday): Able to sit, stand, walk. Run and jump emerging. Capable of walking without a support device, some limit with long distances, stairs, balance, run, jump. ce needed for sitting. Generally walk with a hand-held mobility device. port for sitting. Walk with hand held device, may use/require wheeled mobility. and trunk control. Requires wheeled mobility. h birthday): Walk at home, school, outdoors. May have limits with speed, balance, coordination. gs. Run/jump is limited. May use hand-held device or wheeled mobility. and-held device. May need support in sitting. May need assistance on stairs. sistance or wheeled device. Adaptive seating is required. quired. Unable to fully maintain head/trunk posture or control limb movements. alk in all settings. Able to run and walk, limits in speed, balance, coordination. gs, may use assistive device. Negotiates stairs with railing or assistance. and-held device, may use wheelchair for distances. Transfer to standing may require assistance. sed in most settings. Adaptive seating required. quired. Unable to fully maintain head/trunk posture or control limb movements. Additional Information of the following are present: Language Barrier Impulsive/Aggressive Behavior that interferes with regulation deficit disorder or intellectual disability Lack of consistent caregiver at home (3 goals) - NOTE: Complete applicable section initial goals or follow-up enter goals for previous treatment period and the % success towards the goals. Initial or New Short Term Goals (designed to be met in this authorization period) evious Goals (goals from prior authorization period) Change (Since Start of Care) s the patient/family program? Yes No N/A vicore.com Revised corepath MSK Neurodevelopmental PT Form Page 3 of 5

4 nly Used Standardized Tests r Scale (AIMS) ntal Inventory seretsky Test) sessment of Young Children file 3 st of Visual Perception ion Measure Participation ment Battery for Children ental Motor Scales tion of Activities of Life) r Skills eptual Skills sment of Visual Motor Ability ssessment. ng to age. (Adapted from Palisano RJ, Rosenbaum P, Bartlett D, Livingstone MH. Content validity of the expanded and revised Gross System. Dev Med Child Neurol. 2008, 50: ) y) ove in and out of sitting, floor sit, and manipulate objects while sitting. Infant can crawl and cruise. If between 18 and 24 months, able istance. ntains floor sitting but may need to use hands to maintain balance. Infant creeps or crawls on hand and knees. May be able to pull to ps while holding onto furniture. intain floor sitting when the low back is supported. Able to roll to supine and creep forward on their stomach. trol is present but trunk support is required for floor sitting. Can roll to supine and may roll to prone. mpairments limit voluntary control of movement. Infant is unable to maintain head and trunk postures against gravity. Adult assistance ) r sits with both hand free to manipulate objects. Movements in and out of floor sitting and standing are performed without adult g is the preferred method of mobility without need for assistive mobility device. r sits but may have difficulty with balance when both hands are free to manipulate objects. Movements in and out of sitting are adult assistance. Children pull to stand on a stable surface. Child crawls on hands and knees with a reciprocal pattern, cruise holding walk using an assistive mobility device as the preferred method of mobility. ntains floor sitting often by "W-sitting" (sitting between flexed and internally rotated hips and knees) and may require adult assistance Children creep on their stomach or crawl on hands and knees as the primary method of self-mobility. May pull to stand on a stable short distances. May walk short distances indoors using a hand-held mobility device and adult assistance for steering and turning. r sits when placed, but is unable to maintain alignment and balance without use of hands for support. Adaptive equipment frequently and standing. Self-mobility for short distances (within a room) is achieved through rolling, creeping on stomach, or crawling on hands mpairments limit voluntary control of movement and the ability to maintain head and trunk postures against gravity. All areas of motor. Limitations in sitting and standing are not adequately compensated for with adaptive equipment and assistive technology. Child does ent mobility and must be transported. ) into and out of, and sit in, a chair without the need for hand support. Child moves from the floor and chair to standing with need of. Walk indoors and outdoors and climb stairs. Emerging ability to run and jump. in a chair with both hands free to manipulate objects. Child moves from the floor to standing and from chair sitting to standing but may eir arms to push or pull on an object/surface. Child walks without the need of a mobility device indoors. Can walk for short distances utdoors. Able to climb stairs, but not run or jump. on a regular chair but may require pelvic or trunk support to maximize hand function. Child moves in and out of chair sitting using a assistance. Walks with a hand-held mobility device on level surfaces. Climbs stairs with assistance from an adult. Frequently raveling long distances or outdoors on uneven terrain. on a chair but needs adaptive seating for trunk control and to maximize hand function. Movement in and out of chair sitting requires r a stable surface to push or pull with arms. May be able to walk short distances with a walker and adult supervision but has difficulty aining balance on uneven surfaces. Transportation required in the community. Self-mobility may be achieved with a powered mpairments limit voluntary control of movement and the ability to maintain head and trunk postures against gravity. All areas of motor. Limitations in sitting and standing are not adequately compensated for with adaptive equipment and assistive technology. Child does ent mobility and must be transported. Self-mobility may be achieved with a powered wheelchair and extensive adaptations. vicore.com Revised corepath MSK Neurodevelopmental PT Form Page 4 of 5

5 ay) s at home, school, outdoors, and in the community. Able to walk up and down curbs without assistance and stairs without the use of a ross motor skills such as running and jumping with some limitations in speed, balance, and coordination. May participate in physical s. s in most settings. May experience difficulty when walking long distances, in crowds, up inclines, or carrying objects. Able to walk up ith a railing or with assistance if no railing. In the community and outdoors, may walk with physical assistance, a hand-held mobility eeled mobility for long distances. Minimal ability to perform motor skills like running or jumping. Adaptations may be necessary to n in physical activities and sports. s with a mobility device in most indoor settings. May require a seat belt for pelvic alignment and balance when seated. Transition to physical assistance or a support surface. Wheeled mobility is used for long distances. Child may negotiate stairs with physical ing a railing with supervision. Participation in physical activities and sports requires adaptation including a manual wheelchair or ssistance or powered device is required for mobility in most settings. Adaptive seating is required for pelvic and trunk control. Physical ed for most transfers. Floor mobility, walking short distances with physical assistance, or powered mobility is used at home. Manual or ir is used at school, outdoors, and in the community. Participation in physical activities and sports requires adaptation including a or powered mobility. heelchair is used for transportation in all settings. Child may not be able to maintain head and trunk posture against gravity or control ents. Assistive technology may not compensate for limitations. Transfers require complete physical assistance. Self-mobility requires th extensive adaptations. lk at home, school, outdoors, and in the community. Person is able to walk up and down curbs and stairs without assistance. Able to t speed, balance, and coordination are limited. May participate in physical activities and sports depending on personal and ors. alk in most settings. Environment and personal factors (e.g. uneven terrain, inclines, distance, peer acceptability) affect mobility d mobility device may be used at school or work. Wheeled mobility may be used when traveling long distances outdoors and in the g up or down stairs requires a handrail or physical assistance. Participation in physical activities and sports may require adaptations. alk with hand-held device. Mobility choices may be more varied. Seat belt for pelvic alignment and balance may be required when to standing require physical assistance or a support surface. Wheelchair may be used at school. Transportation in a wheelchair is in the community. Stairs may be negotiated using physical assistance or a railing and supervision. Participation in physical activities uire adaptations, including assistance and/or powered mobility. obility is used in most settings. Adaptive seating is required for pelvic and trunk control. Physical assistance is required for transfers. le to support body weight during transfers, walk short distances with assistance, or use a body walker or wheeled mobility. Capable of heelchair. Participation in physical activities and sports requires adaptations, including assistance and/or powered mobility. heelchair for transportation is required in all settings. Person is limited in ability to maintain head and trunk postures or control arm or ssistive technology may not compensate for limitations. Transfers require complete physical assistance or a mechanical lift. Selfhieved with a powered device and extensive adaptations. vicore.com Revised corepath MSK Neurodevelopmental PT Form Page 5 of 5

Building Better Balance

Building Better Balance The Effects of MS on Balance Individuals with MS experience a decline in their balance due to various MS related impairments. Some of these impairments can be improved with exercise