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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 also say that reevaluation provides additional objective information not included in other 
documentation, such as treatment or progress notes. 
 
Reevaluations are distinct from therapy assessments. Assessments are considered a routine aspect of 
intervention and are not billed separately from the intervention. For example, a patient is being seen in physical 
or occupational therapy for shoulder pain and limited shoulder functional range of motion due to capsular 
tightness. Prior to performing shoulder joint mobilizations, the therapist assesses the patients ROM and pain 
level/pattern to determine the effect of prior treatment and, if further mobilization is warranted, to determine 
the appropriate mobilizations. After the mobilizations are completed, the ROM is assessed again to determine 
the effects of the treatment just performed. The time required to assess the patient before and after the 
intervention is added to the minutes of the treatment intervention. 
 Consider the following points when billing for a reevaluation. 
 
When reevaluations are done for a significant change in condition, documentation must show a significant 
improvement, decline, or change in the patients diagnosis, condition or functional status that was not 
anticipated in the current plan of care. When a patient exhibits a demonstrable change in functional ability, a 
reevaluation may be necessary to revise long term goals and interventions. The plan of care may need to be 
revised and recertified if significant changes are made, such as a change in the long-term goals. 
If a patient is hospitalized during the therapy interval, a reevaluation may be medically necessary if there has 
been a significant change in the patients condition which has caused a change in function, long term goals, 
and/or treatment plan. 
Reevaluations may be appropriate at a planned discharge when documentation supports the medical necessity 
for the reevaluation service. 
You can find this information under Local Coverage Determination (LCD) Outpatient Physical and 
Occupational Therapy Services (L33631). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.