Does Medicare Cover Physical Therapy for Osteoporosis?

Osteoporosis is a condition that weakens bones, making them more susceptible to sudden and unexpected fractures. These fractures can significantly impact an individual’s mobility and overall quality of life. Physical therapy plays an important role in managing osteoporosis by helping to improve balance, strengthen muscles, and reduce the risk of falls and fractures. Many individuals wonder about the extent to which Medicare provides coverage for these rehabilitative services.

Medicare Parts and Physical Therapy Coverage

Medicare offers coverage for physical therapy through its various parts, each addressing different care settings.

Medicare Part A, often referred to as hospital insurance, covers inpatient physical therapy services. This includes therapy required during a hospital stay or as part of recovery in a skilled nursing facility (SNF) after a qualifying hospital stay. For example, if an osteoporosis-related fracture leads to hospitalization or SNF care, physical therapy during these periods falls under Part A.

Medicare Part B primarily covers outpatient physical therapy. This includes services received in a doctor’s office, an outpatient clinic, a rehabilitation center, or at home. Most physical therapy for osteoporosis, aimed at improving strength, balance, and function outside of an inpatient setting, is covered under Part B. This coverage applies to medically necessary services designed to treat a condition, improve function, or prevent further deterioration.

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies. These plans must provide at least the same level of coverage as Original Medicare (Parts A and B). While they cover physical therapy for osteoporosis, their specific rules, such as network restrictions, referral requirements, or cost-sharing structures, can differ from Original Medicare. Beneficiaries should verify their plan’s specific terms regarding physical therapy coverage.

Meeting Medicare’s Coverage Requirements

For Medicare to cover physical therapy, services must be medically necessary. This means the therapy must be deemed essential to diagnose or treat a medical condition, improve function, or slow deterioration. This ensures the therapy is appropriate and meets accepted medical standards for the patient’s specific needs, such as those from osteoporosis.

A physician or another qualified healthcare provider, such as a nurse practitioner or physician assistant, must certify that physical therapy is necessary. This certification typically involves a referral or an order for physical therapy services. The physical therapist then develops a comprehensive plan of care, outlining specific goals, the type of therapy, the frequency and duration of sessions, and expected outcomes.

The referring physician or qualified provider must certify this plan of care, usually within 30 days of the initial evaluation. Medicare also requires periodic re-evaluations by the physical therapist to monitor progress and ensure the therapy continues to meet medical necessity. These re-evaluations are typically conducted at least every 90 days or with a significant change in the patient’s condition.

Your Financial Contribution

Understanding the financial obligations for physical therapy under Medicare is important.

For outpatient physical therapy covered by Medicare Part B, beneficiaries are responsible for certain out-of-pocket costs. After meeting the annual Part B deductible, which is $240 for 2024 and $257 for 2025, Medicare typically covers 80% of the approved amount. The beneficiary is responsible for the remaining 20% coinsurance.

For example, if a session costs $100 and the deductible is met, Medicare pays $80, and the beneficiary pays $20. These costs can accumulate, especially for ongoing therapy. While Medicare does not impose a hard cap on total payment for medically necessary physical therapy, a therapy threshold exists. This threshold is $2,330 for 2024 and $2,410 for 2025, for combined physical therapy and speech-language pathology services.

If therapy costs exceed this threshold, the physical therapist must document that the services remain medically necessary for Medicare to continue coverage. Medicare Advantage plans may have different cost-sharing, such as copayments per visit, but must offer at least the same benefits as Original Medicare. Check with your specific Medicare Advantage plan for details on deductibles, copayments, and prior authorization requirements.

Navigating the Process to Receive Care

Accessing covered physical therapy for osteoporosis begins with your healthcare provider. Your doctor can assess your condition, confirm the need for therapy, and provide the necessary referral or order. While Original Medicare generally does not require a referral for outpatient physical therapy, a physician’s order and certification of the plan of care are essential for coverage.

Once you have a referral or order, find a Medicare-approved physical therapist or clinic. Medicare’s official website offers a search tool to locate approved providers in your area, or your doctor may provide recommendations. Confirm the chosen physical therapist accepts Medicare assignment to ensure they accept the Medicare-approved amount as full payment.

During your initial visit, the physical therapist will evaluate your mobility, strength, and overall functional status related to your osteoporosis. This evaluation helps them develop a personalized plan of care tailored to your specific needs and goals. Subsequent sessions implement this plan, with regular progress monitoring to ensure the therapy remains effective and medically necessary.