Physical therapy denials
Physical, occupational, and speech therapy are denied after a visit cap, when the plan decides progress has stopped, or when it labels care 'maintenance'. Denials are small per visit and large in total, and the maintenance argument is often wrong.
What gets denied
- Visits beyond a plan's annual limit
- Continued therapy after the plan decides the patient has plateaued
- Habilitative therapy for children with developmental conditions
- Therapy after surgery when the plan's protocol allows fewer visits
- Speech therapy for stroke, brain injury, or developmental delay
Common denial reasons
- Plan says the patient has reached 'maximum medical improvement'
- Care labeled 'maintenance' or 'could be done as a home program'
- Progress notes lack measurable functional goals
- Visit limit reached under the plan's benefit design
- Referral or plan of care not signed or renewed
How we approach the appeal
Ask for the plan's therapy criteria and the visit limit language in the plan document. Have the therapist rewrite the plan of care with measurable functional goals and document why a skilled therapist, not a home program, is required. For Medicare and Medicare Advantage, cite the maintenance-coverage standard. For habilitative services, cite the essential-health-benefit requirement and check for a state mandate. If the denial is a benefit limit rather than medical necessity, the appeal is about whether the limit was applied correctly and whether an exception exists.
Internal appeal: at least 180 days to file for commercial and employer plans; pre-service decisions within 30 days, post-service within 60 (29 CFR 2560.503-1). Medicare Advantage: 65 days to request reconsideration. Ongoing therapy after surgery or stroke may qualify as urgent (72-hour decision).
Individual visits are modest, but a denied course of therapy over months adds up to a meaningful sum; the amount at stake is the plan's allowed amount times the denied visits.
- · The denial letter and the plan's visit-limit or criteria language
- · Physician referral and signed plan of care
- · Therapy evaluation and progress notes with functional measures
- · Surgical or hospital records where therapy follows an event
- · Any prior authorization approvals and their dates
Physical therapy denial? Let's appeal it.
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Start Your AppealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.