Appeal type: Outpatient Therapies
Decision: Partially Favorable

 We decided that the Plan has to pre-approve three additional visits. We decided that the Plan does not have to 
pre-approve the remaining seven visits.  
 
You asked the Plan to pre-approve ten additional physical therapy visits.. You say that you need to continue 
with physical therapy, so you may continue to improve walking. The Plan says that based on the clinical notes, 
medical necessity criteria has not been met. 
 
We decided that the Plan has to pre-approve three additional visits.  
 
The Plan follows Medicare rules. Medicare rules say that payment will be made 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 additional 
requested therapy is generally accepted as specific and effective therapy for your condition. The records do  not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist for ten more sessions. However, an additional three sessions is needed to review stair 
safety and practice, ensure competence in an home exercise program, and review safety with assistive device, 
you are just starting to use a cane. The requested services are not part of a maintenance program and the 
specialized skill, knowledge and judgment of a qualified therapist is reasonable for three more sessions to 
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
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 additional visits have been met. Therefore, we decided that the Plan has to 
pre-approve three additional visits.  
 
We also decided that the Plan does not have to pre-approve the remaining seven visits. 
 
The Plan follows Medicare rules. Medicare rules say that payment will be made 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 visits. Our reviewer says that the 
remaining seven formal therapy sessions are not considered medically reasonable and necessary. These 
services do not need to be performed only by a therapist, or by or under the supervision of a therapy sessions 
for these seven 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 seven visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the remaining seven 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.