Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 12 visits. We decided that the Plan does not have to pre-approve 
12 visits.   
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan says that there 
has been enough time since the start of care to instruct and transition to a home program. 
 
We decided that the Plan has to pre-approve 12 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 for the visits. Our reviewer says that as of 5/27/22, you 
have received 40 visits of physical therapy. The progress note from 5/27/22 indicates that the enrolle has 
improved in terms of performing transfers. The enrollee continues to have difficulty with ambulation and 
require assistance. You are walking 70 feet with minimal assistance in comparison to 4/15/22 when you were 
walking 50-60 feet with minimal assistance. The enrollee continues to require moderate assistance for transfers. 
The requested therapy is generally accepted as a specific and effective therapy for your weakness and impaired 
mobility. The enrollee continues to have functional deficits regarding mobility and transfers and may continue 
to make gradual gains with therapy and an independent exercise program. Therefore, an additional 12 visits of 
therapy can be considered medically necessary to integrate a home exercise program and for periodic 
assessment. 
 
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 visits have been met. Therefore, we decided that the Plan has to pre-approve 
12 visits.  
 
We also decided that the Plan does not have to pre-approve 12 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 for the other 12 visits. Our reviewer says that these 
additional visits are not medically reasonable or necessary. Our physician reviewer found that given the current 
documented progression with ongoing therapy, it is not clear that the amount, frequency, and duration of the 
services are reasonable under accepted standards of practice and that the services of a skilled therapist are 
required at this frequency and amount. Although the first 12 visits are reasonable and necessary, the full 24 
requested visits are not reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 12 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.