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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.
The rules say that patients with long term, chronic conditions may occasionally need skilled input to update or
revise their home maintenance program; and to assess the need for new, or changes to existing, assistive or
adaptive equipment. Periodic evaluations of the patient's condition and response to treatment may be covered
when medically necessary if the judgment and skills of a qualified professional are required. Examples include:
Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in
patients suffering from a chronic disease. Instructing the patient, family member(s) or caregiver(s) in carrying
out the maintenance program. Infrequent re-evaluations required to assess the patient's condition and adjust the
program. If a maintenance program is not established until after the therapy program has been completed (and
the skills of a therapist are not necessary), development of a maintenance program is not considered reasonable
and necessary for the patient's condition.
It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do
not require the professional skills of a qualified professional. These situations include: Services related to
activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and
flexibility). Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such
as that provided in support for feeble or unstable patients. Range of motion and passive exercises that are not
related to restoration of a specific loss of function but are useful in maintaining range of motion (for example:
in paralyzed extremities). Maintenance therapies after the patient has achieved therapeutic goals or for patients
who do not require skilled care and should become patient- or caregiver-directed. Documentation, either with
objective evidence or a clinically supportable statement of expectation, must be available that supports the
necessity of the skilled services provided. General Modality Guidelines: Modality codes for mechanical
traction, unattended electrical stimulation, vasopneumatic device, paraffin bath therapy, whirlpool therapy,
diathermy, and ultraviolet therapy, require supervision by the qualified professional. Modality codes for
manual electrical stimulation, contrast bath therapy, ultrasound therapy, hydrotherapy, and physical therapy
treatment unlisted require direct (one-on-one) contact with the patient by the qualified professional. Generally,
adjunctive use of services billed with mechanical traction and paraffin bath therapy is coverable only if they enhance the therapeutic procedures. Documentation supporting the medical necessity and clinical justification
for the continued use of these services must be made available to Medicare upon request. Generally, only one
heating modality per day of therapy is reasonable and necessary. Medicare would not expect to see multiple
heating modalities billed routinely on the same day. Exceptions could include musculoskeletal
pathology/injuries in which both superficial and deep structures are impaired. Documentation containing
clinical justification supporting the medical necessity for multiple heating modalities such as paraffin bath
therapy, diathermy, and ultrasound therapy on the same day is essential. Generally, only one hydrotherapy
modality is coverable per day when the sole purpose is to relieve muscle spasm, inflammation or edema.
Documentation must be available supporting the use of multiple modalities as contributing to the patient's
progress and restoration of function. Because some of the modalities are considered components of other
modalities and procedures, they are not separately reimbursed. Please refer to the National Correct Coding
Initiative. You can find this information in Medicare's 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.