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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 services that do not require the professional skills of a therapist to perform or supervise are 
not medically necessary, even if they are performed or supervised by a therapist, physician or NPP. The skills 
of a therapist may also be furnished by an appropriately trained and experienced physician or NPP, or by an 
assistant (PTA, OTA) appropriately supervised by a therapist. Therefore, if a patients therapy can proceed 
safely and effectively through a home exercise program, self management program, restorative nursing 
program or caregiver assisted program, payment cannot be made for therapy services. 
 
Consider the following when determining if a service is skilled. 
 
The services shall be of such a level of complexity and sophistication or the condition of the patient shall be 
such that the services required can only be safely and effectively performed by a qualified clinician, or 
therapists supervising assistants.  
Maintenance therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in 
each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is to 
maintain functional status or to prevent or slow further deterioration in functional status. 
 
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. 
If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver 
regarding the maintenance program, such instruction is covered. 
If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, 
such periodic reevaluations or reassessments are covered. 
Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) 
the therapy procedures required to maintain the patients current function or to prevent or slow further 
deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to 
furnish the therapy procedure or (b) the particular patients special medical complications require the skills of a 
qualified therapist to furnish a therapy service required to maintain the patients current function or to prevent 
or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy 
procedures. 
If at any point in the treatment it is determined that the treatment becomes repetitive and does not require the 
unique skills of a therapist, the services are non-covered. 
There may be circumstances where the patient, with or without the assistance of an aide or other caregiver, 
does activities planned by a clinician. Although these activities may be supportive to the patients treatment, if 
they can be done by the patient, aides or other caregivers without the active participation of qualified 
professional/auxiliary personnel, they are considered unskilled. 
An individualized plan of exercise and activity for patients and their caregiver(s) may be developed by 
clinicians to maintain and enhance a patients progress during the course of skilled therapy, as well as after 
discharge from therapy services. Such programs are an integral part of therapy from the start of care and should 
be updated and modified as the patient progresses. 
If a patients limited ability to comprehend instructions, follow directions, or remember skills that are necessary 
to achieve an increase in function, is so severe as to make functional improvement very unlikely, rehabilitative 
therapy is not required, and therefore, is not covered. However, limited services in these circumstances may be 
covered with supportive documentation, if the skills of a therapist are required to establish and teach a 
caregiver a safety or maintenance program. 
This does not apply to the limited situations where rehabilitative therapy is reasonable and achieving 
meaningful goals is appropriate, even when a patient does not have the ability to comprehend instructions, 
follow directions or remember skills. Examples include sitting and standing balance activities that help a 
patient recover the ability to sit upright in a seat or wheel-chair, or safely transfer from the wheelchair to a 
toilet. 
This also does not apply to those patients who have the potential to recover abilities to remember or follow 
directions, and treatment may be aimed at rehabilitating these abilities, such as following a traumatic brain 
injury. 
The use of therapy equipment such as therapeutic pools or gym machines alone does not necessarily make the 
treatment skilled. 
Medicare does not cover packaged or predetermined therapy services or programs, such as Back Schools or 
pre-operative joint classes with preset educational activities and exercises for all participants involved. Services 
must be individualized, medically necessary and require the unique skills of a therapist. (Packaged or 
predetermined therapy services do not apply to post-surgical protocols that provide ranges and guidance.) 
 
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 in the 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.