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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, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. The rules say that 1. PT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as PT (i.e., turning patients to prevent pressure injuries, walking a patient in the hallway postoperatively or ambulation without gait training). 2. Covered PT must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment regimen established by the physician or NPP after any necessary consultation with the qualified physical therapist, or by the physical therapist providing the services and must be reasonable and necessary to the treatment of the individual's illness or injury. 3. In order for the plan of treatment to be covered, it must address a condition for which PT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a
condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage. 4. PT is only covered when it is rendered under a written plan of treatment established by the physician, NPP or the qualified physical therapist, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment. 5. The physician or NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable. You can find this information in Medicare's Local Coverage Determination (LCD): Outpatient Physical Therapy (L34428).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.