Medicare Denied Your Rehabilitation / PT / OT?
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.Sources include KFF ACA Marketplace Transparency Data, HHS OIG reports, and state insurance department filings. Aggregate rates are context, not predictions for an individual case.
Based on published government and industry research. Individual results vary based on denial type, insurer, and documentation.
Why they said no
Why Medicare Denies Rehabilitation / PT / OT
Maximum therapy visits reached for the year
Not making sufficient progress toward goals
Treatment deemed maintenance rather than restorative
Medicare patterns
Medicare's Common Denial Patterns
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 Rehabilitation / PT / OT Appeal
Therapist documentation of measurable functional improvement
Updated treatment plan with specific, measurable goals
Physician letter explaining medical necessity of continued therapy
Your rights
Laws That Protect You
ACA — Rehabilitative and habilitative services as EHB
Jimmo v. Sebelius — improvement not required for Medicare coverage
Mental Health Parity and Addiction Equity Act
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
Rehabilitation / PT / OT denials by other insurers
This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.