Medicare Denied Your Physical Therapy?
Published data shows denial and appeal outcomes vary by plan, product year, denial reason, and documentation. Use this page to spot the issues to request and the evidence to gather before you decide what to submit.This template provides issues to verify, not insurer-specific outcome or deadline predictions. Your denial notice, current plan document, claim status, and governing program control.
Deadlines and review routes depend on plan type, urgent or standard status, whether care has already occurred, jurisdiction, and review level. Use the dates and instructions in the denial notice and current plan documents.
Why they said no
Common reasons Physical Therapy claims are denied
Visit limit exceeded per plan year
Maintenance therapy — no longer improving
Prior authorization expired or not renewed
Medicare checks
Issues to check in the Medicare notice
Denying claims as not reasonable and necessary
Coverage determinations based on LCD/NCD criteria
Denying skilled nursing facility stays as custodial care
What works
How to Strengthen Your Physical Therapy Appeal
Objective measurement of functional progress (ROM, strength, balance scores)
Treatment plan with specific, measurable goals
Documentation that cessation would cause regression
For Medicare: cite the Jimmo v. Sebelius settlement, which clarifies that improvement is not required for coverage — skilled care to maintain function or slow decline can be covered when all other coverage requirements are met
Rules to verify
Rights and coverage rules that may apply
The plan’s rehabilitation benefit, visit limits, and authorization rules — coverage varies by product and setting
Jimmo settlement principles — for Medicare, lack of improvement cannot be the sole reason to deny otherwise-covered skilled care; all other coverage requirements still apply
State rehabilitation mandates — apply only to specified services and state-regulated plans
Playbook
Tips for Appealing to Medicare
Medicare has a 5-level appeal process with different evidence and deadline rules at each level
Request an ALJ hearing if redetermination and reconsideration fail
Cite specific LCD/NCD criteria and explain how your case meets them
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Related denial guides
More Medicare denials
Physical Therapy denials by other insurers
This information is for educational and informational purposes only. It does not constitute legal or medical advice. This page cites no statistics; it lists issues to verify against your own denial notice, plan documents, and the governing rules. Individual results vary. Consult a qualified professional before taking action on your specific situation.