Physical therapy denials

How we approach the appeal

The decisive question is whether the denial says you stopped improving or says you ran out of visits, because they are different arguments. If the letter uses the language of plateau, maintenance, maximum medical improvement, or says the work could be done as a home programme, that is the improvement standard, and for Medicare it is not a lawful basis on its own. The Jimmo v. Sebelius settlement confirmed that skilled therapy is covered where the skill of a therapist is needed to maintain function or to slow deterioration, even when no further improvement is expected. Making that argument concrete is what wins: the notes have to show why a licensed therapist is required rather than a carer or a handout, which usually means documenting the clinical judgement being exercised, the safety risk being managed, the adjustments made session to session, and what specifically would deteriorate without skilled input. Measurable functional goals expressed in daily activity, such as transfers, stair negotiation, gait distance or fall incidents, carry far more weight than range-of-motion numbers alone. If instead the plan has applied a hard visit cap, the argument is different: check whether the cap is a true plan exclusion or a soft limit that medical necessity can exceed, and for Medicare note that the therapy threshold is not a cap at all but a point at which additional documentation is required, which the provider can supply. For children denied habilitative therapy, the mental health and substance use parity rules and many state habilitative-services mandates are additional routes, because habilitative care is a required benefit category in most plans rather than an optional one.