Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve twenty (20) physical therapy visits. We decided that the Plan 
does not have to pre-approve twenty (20) physical therapy visits. 
 
You asked the Plan to pre-approve forty (40) physical therapy visits. You say that the medical records provided 
support the need for the physical therapy visits. The Plan says based on clinical presentation, the enrollees 
condition is stable and skilled therapy is not required to maintain the enrollee's current condition. 
 
We decided that the Plan has to pre-approve twenty (20) physical therapy visits.  
 
The Plan must follow 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 forty (40) physical therapy visits. Our 
reviewer says that twenty (20) physical therapy visits are medically reasonable and necessary. The requested 
therapy is generally accepted as a specific and effective therapy for the enrollee's lower extremity weakness 
due to an axonal sensorimotor neuropathy. The documentation indicates that the enrollee had an 
electromyography performed which showed an axonal sensorimotor neuropathy. Currently the enrollee can 
walk 420 feet versus 210 feet using a walker and is able to do some stairs. While the enrollee's progress has 
been slow, there have been improvements in terms of distal motor strength and ability to ambulate longer 
distances. The enrollee still has functional deficits with mobility, in particular negotiating stairs. Therefore, 
additional therapy and the skills of a physical therapist would be appropriate to continue to meet these goals 
and transition to a home exercise program to ensure independence and minimize fall risk. Therefore, our 
physician reviewer found that the enrollees condition meets criteria for coverage of twenty (20) additional 
therapy visits.  
 
We looked at the physicians review file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of twenty (20) physical therapy visits have been met. Therefore, we decided that the Plan has to 
pre-approve twenty (20) physical therapy visits. 
 
We also decided that the Plan does not have to pre-approve twenty (20) physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
 
We looked at the physicians review file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of twenty (20) physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twenty (20) 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.