Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve the additional PT visits. We decided that the Plan does not have to pre-approve 2 physical therapy visits.
You asked the Plan to pre-approve the additional PT visits. You say that due to her significant decline in strength, gait and balance, the enrollee would benefit from skilled physical therapy to decrease her fall risk at home and in the community. The Plan says that the additional physical therapy visits is not medically necessary for the enrollee at this time.
The Plan follows Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer says that the enrollee partially meets the Medicare criteria for the physical therapy visits. Our physician reviewer found the additional 2 of the 4 requested therapy visits is accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy and the records do not demonstrate that the enrollee requires all 4 of the requested therapy sessions with the unique skills of a professional therapist to safely and effectively provide treatment. The services do not require 4 visits to be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. While the requested 4 visits are not medically necessary the documentation does not clearly indicate that the enrollee has been thoroughly instructed in a home exercise program. The requested services are not part of a maintenance program, but the specialized skill, knowledge and judgment of a qualified therapist is required to establish a home exercise program. Therefore, the request has been partially met and two of the requested four visits are medically necessary to enforce and transition to an independent home exercise program. The remaining two of the requested 4 visits are not medically necessary.
We decided that the Plan has to pre-approve 2 physical therapy visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional PT visits have been met. Therefore, we decided that the Plan has to pre-approve 2 physical therapy visits.
We also decided that the Plan does not have to pre-approve 2 physical therapy visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 physical therapy visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.