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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when: 1. The services are specific and effective treatment for the patient's condition, 2. The services require the skills or direct supervision of a therapist, 3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and 4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program. Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. Medicare covers therapy services personally performed only by one of the following: a. Licensed therapy professionals: licensed physical therapists and occupational therapists. b. Licensed PTA with appropriate supervision by a licensed physical therapist. Please refer to CMS Publication 100-02, Chapter 15, Section 230.5(C) for information regarding therapy services provided by licensed physical therapy assistants (PTAs). c. Licensed occupational therapy assistants (OTAs) with appropriate supervision by a licensed occupational therapist. Please refer to CMS Publication 100-02, Chapter 15, Section 230.2(C) for information regarding therapy services provided by OTAs.
d. Medical Doctors (MDs) and Doctors of Osteopathy (DOs). e. Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses', scope of practice and their training and competency. f. Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNSs) when performing services within their licenses' scope of practice and their training and competency (ANP, PA, CNS). g. "Qualified" personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services "incident to" a physician have been met. Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services "incident to" the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed. Please note that unless these therapy services are performed by a "qualified" person, the services are not covered and must not be reported for Medicare payment. You can find this information in Local Coverage Determination (LCD): Therapy and Rehabilitation Services (PT, OT) (L35036).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.