Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 4 visits.. We decided that the Plan does not have to pre-approve 6 
visits.  
 
You asked the Plan to pre-approve 10 additional physical therapy visits.. You say that you need more physical 
therapy. The Plan says that an additional 10 physical therapy visits are not medically necessary. 
 
We decided that the Plan has to pre-approve 4 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 physical therapy visits. Our reviewer says that 
four additional visits are reasonable and necessary. Our physician reviewer found that the requested therapy is 
generally accepted as a specific and effective therapy for the patient's neck pain. The physical therapy 
evaluation dated 11/4/2022 indicated that the patient was reporting of 8/10 pain that interferes with her daily 
activities. The patient was noted to have 3/5 motor strength in the lower extremities and decreased range of 
motion in the cervical spine. The patient was noted to have functional deficits. Physical therapy is indicated, 
and 12 sessions of physical therapy would be more appropriate in terms of improving function, decreasing 
pain, and establishing a home exercise program. Therefore, 4 visits of physical therapy (on top of the 8 already 
approved) can be considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits. have been met. Therefore, we decided that the Plan has 
to pre-approve 4 visits.  
 
We also decided that the Plan does not have to pre-approve 6 visits. 
 
"The Plan follows Medicare rules. Medicare rules say that 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 remaining physical therapy visits. Our reviewer 
says that the other eight additional visits are not reasonable and necessary. Our physician reviewer found that 
after 12 sessions of treatment, a re-evaluation can be performed to determine the necessity of continued 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 visits have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 6 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.