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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 to be considered reasonable and necessary, the services must meet Medicare guidelines. 
The guidelines for coverage of outpatient therapies have basic requirements in common. 
 
In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in 
response to therapy, maximum improvement is yet to be attained; and there is an expectation that the 
anticipated improvement is attainable in a reasonable and generally predictable period of time. 
 
Improvement is evidenced by successive objective measurements whenever possible. If an individuals 
expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services 
required to achieve such potential, rehabilitative therapy is not reasonable and necessary. 
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and 
easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activates (CMS Publication 100.02-, Medicare benefit Policy Manual, 
chapter 15, section 220.2). For example, therapy may not be covered for a fully functional patient who 
developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably 
expected that as discomfort reduces and the patient gradually resumes daily activities, function will return 
without skilled therapy intervention. 
 
In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further 
deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary 
him or herself, a family member, another caregiver, or unskilled personnel. 
A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide 
the physical therapy services, or the occupational therapist who will provide the occupational therapy services, 
(only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP. 
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs 
the unique skills of a therapist to improve functioning. 
If the goal of the plan of care is to maintain, prevent, or slow further deterioration of functional status function 
or prevent deterioration, the documentation must establish that the patient needs the unique skills of a therapist 
to maintain, prevent, or slow further deterioration of functional status. 
 
All services provided are to be specific and effective treatments for the patients condition according to 
accepted standards of medical practice; and the amount, frequency, and duration of the services must be 
reasonable. 
 
You can find this information under Local Coverage Determination (LCD) Outpatient Physical and 
Occupational Therapy Services (L34049). 
 
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.