Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 3 sessions. We decided that the Plan does not have to pre-approve 
the remaining 15 sessions.   
You asked the Plan to pre-approve the services. You say that the enrollee could significantly improve in 
maximizing range of motion (ROM), improvement of daily activities, functional mobility and minimize pain if 
the request is approved. The Plan says that the Medicare criteria for this therapy has not been met. 
 
We decided that the Plan has to pre-approve 3 sessions.  
 
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. The documentation is not clear if the 
enrollee is versed in a home exercise program. Our reviewer says that three sessions would allow for ample 
time for proper instruction in a home exercise program, given the enrollee's extensive prior history of therapy. 
Therefore, three of the eighteen sessions are reasonable with a transition to a home exercise program. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve 3 sessions.  
 
We also decided that the Plan does not have to pre-approve the remaining 15 sessions. 
 
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 the remaining 15 
sessions of the requested 18 sessions are not medically necessary. Our physician reviewer found that these 15 
sessions would not generally be accepted as specific and effective therapy for the enrollee's condition. The 
patient has had prior extensive therapy and the documentation does not reveal that the patient requires the 
remaining 15 of the requested 18 sessions of therapy with the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or under the supervision of a therapist. The requested services are not part of a maintenance 
program.  The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a home exercise program to maintain the patient's current condition beyond three 
sessions. 
 
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 remaining 15 sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the remaining 15 sessions. 
 
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.