Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two additional physical therapy visits. We decided that the Plan 
does not have to pre-approve eight additional physical therapy visits. 
 
You asked the Plan to pre-approve ten additional physical therapy visits. You say that your grip strength has 
improved from 66 right/35 left on August 2, 2023 to 84 right/48 left on August 23, 2023, which you feel is 
significant improvement. The Plan says that the request is not medically necessary. 
 
We decided that the Plan has to pre-approve two additional physical therapy visits.  
 
The Plan follows Medicare rules. Medicare rules say that if the specialized skill, knowledge and judgment of a 
qualified therapist are required to establish or design a maintenance program to maintain the patients current 
condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by 
a qualified therapist is covered. 
 
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 the therapy services. Our reviewer says 
that two of the ten therapy sessions are reasonable and medically necessary. Our physician reviewer found it is 
reasonable to have two more sessions of the specialized skill, knowledge and judgment of a qualified therapist 
to review and ensure full competence in 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 two additional physical therapy visits have been met. Therefore, we decided 
that the Plan has to pre-approve two additional physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve eight additional physical therapy visits. 
 
The Plan follows Medicare rules. Medicare rules say that the documentation must establish that the patient 
needs the unique skills of a therapist to maintain, prevent or slow further deterioration of functional status. 
 
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 eight additional physical therapy visits. 
Our reviewer says that the additional eight out of ten requested therapy sessions are not generally accepted as 
specific and effective therapy for your condition. Our physician reviewer found the records do not demonstrate 
that the unique skills of a professional therapist are required to safely and effectively provide treatment. The 
services do not need to be safely and effectively performed only by a therapist, or by or under the supervision 
of a therapist beyond two more skilled therapy visits.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight additional physical therapy visits. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve eight additional physical 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.