RXTAFO170913
Document of Medical Necessity : Thermoplastic AFO
Patient Name : _______________________________________
HICN : __________________________ Prognosis : Good Duration of usage : 12 Months Quantity : � Bilateral � Unilateral
I certify that Mr . / Ms . ____________________________________________ qualifies for and will benefit from an ankle foot orthosis used during ambulation based on meeting all of the following criteria . The patient is :
• Ambulatory , and
• Has weakness or deformity of the foot and ankle , and
• Requires stabilization for medical reasons , and
• Has the potential to benefit functionally
The patients medical record contains sufficient documentation of the patient ' s medical condition to substantiate the necessity for the type and quantity of the items ordered .
The goal of this therapy : ( indicate all that apply )
� Improve mobility
� Improve lower extremity stability
� Decrease pain
� Facilitate soft tissue healing
� Facilitate immobilization , healing and treatment of an injury Necessity of Ankle Foot Orthotic molded to patient model :
A custom ( vs . prefabricated ) ankle foot orthosis has been prescribed based on the following criteria which are specific to the condition of this patient . ( indicate all that apply )
� The patient could not be fit with a prefabricated AFO
� The condition necessitating the orthosis is expected to be permanent or of longstanding duration ( more than 6 months )
� There is need to control the ankle or foot in more than one plane
� The patient has a documented neurological , circulatory , or orthopedic condition that requires custom fabrication over a model to prevent tissue injury
� The patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions
I hereby certify that the ankle foot orthotic described above is a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body . It is designed to provide support and counterforce on the limb or body part that is being braced . In my opinion , the custom molded thermoplastic AFO is both reasonable and necessary according to accepted standards of medical practice in the treatment of the patient ’ s condition and rehabilitation .
Signature of Prescribing Physician : ______________________________________ Type I NPI : _____________ Date : ______/______/______
Printed Name of Prescribing Physician ________________________________________ Phone : _____________________________________
TM