Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuromuscular reeducation (97112), group adaptive 
behavior treatment by protocol, administered by technician under the direction of a physician or other qualified 
health care professional (97154), therapeutic exercises (97110), manual therapy techniques (97140), ultrasound 
therapy (97035), gait training therapy (97116), self-care/home management training (97535) and electrical 
stimulation (97032). 
 
  You asked the Plan to pre-approve neuromuscular reeducation (97112), group adaptive behavior treatment by 
protocol, administered by technician under the direction of a physician or other qualified health care 
professional (97154), therapeutic exercises (97110), manual therapy techniques (97140), ultrasound therapy 
(97035), gait training therapy (97116), self-care/home management training (97535) and electrical stimulation 
(97032). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
does not meet the medical necessity guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 neuromuscular reeducation (97112), 
group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or 
other qualified health care professional (97154), therapeutic exercises (97110), manual therapy techniques 
(97140), ultrasound therapy (97035), gait training therapy (97116), self-care/home management training 
(97535) and electrical stimulation (97032). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found after the patient 
received 16 visits of physical therapy, the lumbar spine range of motion and motor strength did not improve. 
Our physician reviewer also found that though an occupational therapy evaluation shows the patient requires 
assistance with her daily activities, this does not necessitate continued physical therapy unless the patient is 
demonstrating improved function with 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 neuromuscular reeducation (97112), group adaptive behavior treatment by 
protocol, administered by technician under the direction of a physician or other qualified health care 
professional (97154), therapeutic exercises (97110), manual therapy techniques (97140), ultrasound therapy 
(97035), gait training therapy (97116), self-care/home management training (97535) and electrical stimulation 
(97032) have not been met. Therefore, we decided that the Plan does not have to pre-approve neuromuscular 
reeducation (97112), group adaptive behavior treatment by protocol, administered by technician under the 
direction of a physician or other qualified health care professional (97154), therapeutic exercises (97110), 
manual therapy techniques (97140), ultrasound therapy (97035), gait training therapy (97116), self-care/home 
management training (97535) and electrical stimulation (97032).