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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 The cornerstones of rehabilitative therapy are mobilization, education and therapeutic exercise. The goal of rehabilitative medicine is discernible, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. To that end, the dynamic components of therapy, mobilization, and patient education should predominate. Passive modalities should be used in the "warm-up" phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the "cool-down" phase for reduction of pain, swelling and other post-treatment syndromes. Though passive modalities may predominate in the earlier phases of rehabilitation where the patient's ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. Further, Medicare expects the patient's record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care. In more refractory cases, the practitioner will support the need for continued care with documentation that clearly outlines the factors that require continued skilled care. The contractor recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to require the services of a skilled caregiver. In all cases, whether the duration and intensity of rehabilitative services recommended or rendered are limited or extensive for passive or active services, Medicare expects the patient's medical record to clearly demonstrate medical reasonableness and necessity for all therapy services. When a service is provided beyond a patient's Medicare benefit and it is determined to be not medically necessary, it is denied by Medicare as a benefit category denial. Therapeutic exercise and activities are essential for rehabilitation. The use of modalities as stand-alone treatment is not indicated as a sole approach to rehabilitation. Therefore, an overall course of rehabilitative treatment is expected to consist predominantly of therapeutic procedures (such as therapeutic exercises, neuromuscular re-education, gait training therapy, or therapeutic activities), with adjunctive use of modalities. Although passive modalities may play a larger role in the early stages of rehabilitation and in treating
exacerbations it is expected that modalities will comprise a small portion of the total therapy service time involved during the course of rehabilitative therapy. Further, it is expected that the record will demonstrate both the patient's clinical progress and concomitant appropriate increasingly active therapeutic treatment. MAINTENANCE THERAPY Refer to CMS IOM Publication 100-02, Chapter 15, Section 220.2(D) for complete information regarding maintenance therapy. A maintenance program consists of activities that preserve the patient's present level of function or prevent regression of that function. 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. 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.