Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 additional occupational therapy visits. We decided that the 
Plan does not have to pre-approve 4 additional occupational therapy visits.  
 
You asked the Plan to pre-approve 10 additional occupational therapy visits.. You say that 10 additional 
occupational therapy visits are medically necessary. The Plan says that 10 additional occupational therapy 
visits are not medically necessary. 
 
We decided that the Plan has to pre-approve 6 additional occupational therapy 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 to pre-approve 6 additional occupational therapy visits. 
Our reviewer says that 6 of the 10 occupational therapy visits are medically necessary. Our physician reviewer 
found the documentation indicates that the enrollees elbow range of motion and ability to perform daily 
activities has improved with therapy and she is no longer requiring the use of her elbow brace for pain and 
stabilization. She continues to make improvements in her independence with performing her daily activities, 
including dressing. She would benefit from an additional 6 sessions of occupational therapy to maximize 
improvement and 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 6 additional occupational therapy visits have been met. Therefore, we decided 
that the Plan has to pre-approve 6 additional occupational therapy visits.  
 
We also decided that the Plan does not have to pre-approve 4 additional occupational therapy 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 to pre-approve 4 additional occupational therapy visits. 
Our reviewer says that 4 of the 10 occupational therapy visits are not medically necessary. Our physician 
reviewer found 6 sessions of occupational therapy should maximize improvement and allow 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 4 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 4 additional occupational therapy 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.