How to Get Insurance to Pay for More Physical Therapy
Maximize your physical therapy benefits. Discover strategies to extend coverage, understand your policy, and successfully appeal denials for continued recovery.
Physical therapy aids recovery and improves well-being after injuries, surgeries, or for chronic conditions. While often necessary for restoring function, navigating insurance coverage can be challenging, especially for continued sessions beyond initial approvals. This article guides understanding insurance benefits and securing necessary physical therapy coverage.
Understanding Your Policy Coverage
Understanding your health insurance policy is the first step in managing physical therapy costs. Policy details are available through your insurer’s online member portal, Summary Plan Description, or by contacting member services. These resources provide a clear overview of your benefits.
Your health insurance plan involves several key financial terms. A deductible is the amount you pay out-of-pocket for covered medical services before insurance begins to pay. For instance, a $2,000 deductible means you are responsible for the first $2,000 of covered annual costs. Once met, your plan might cover a percentage of costs, known as coinsurance. A common coinsurance arrangement is 80/20, where the insurer pays 80% and you pay the remaining 20%.
A copayment, or copay, is a fixed dollar amount paid at the time of service, such as a doctor’s visit or physical therapy session. Copays typically range from $20 to $75 per session. These fixed fees generally do not count towards your deductible, but they do contribute to your out-of-pocket maximum.
The out-of-pocket maximum is the annual limit on what you pay for covered healthcare services, including deductibles, copayments, and coinsurance. After reaching this limit, your insurer covers 100% of in-network services for the remainder of the year. For 2025, individual out-of-pocket maximums are capped at $9,450 and $18,900 for families under the Affordable Care Act.
Many policies impose visit or duration limits for physical therapy, such as “20 visits per year” or coverage for a specific number of days. Some plans may require pre-authorization after a certain number of visits, often after 6-8 sessions. A key requirement for physical therapy coverage is “medical necessity,” meaning services are needed for a medical condition’s diagnosis or treatment and meet accepted medical standards. Before beginning or continuing treatment, proactively verify your physical therapy benefits and any pre-authorization requirements by contacting your insurance company, ideally getting information in writing.
Strategies for Extending Physical Therapy Coverage
Extending physical therapy coverage depends on robust documentation and clear communication between the patient, physical therapist, and referring physician. Both play a key role in articulating the ongoing medical necessity for continued care. Their detailed records justify additional sessions to the insurance company.
Comprehensive progress notes clearly articulate a patient’s functional improvements or persistent limitations necessitating continued care. These notes should include objective measures, such as improvements in range of motion or strength, and the patient’s response to therapy. They also assess progress toward each goal and inform decisions regarding treatment plan continuation. Updated treatment plans are important, outlining specific, measurable goals, the rationale for ongoing therapy, and the expected duration and frequency of sessions.
Functional outcome measures provide quantifiable data demonstrating a patient’s progress or persistent limitations, strengthening the case for continued treatment. An updated physician’s referral or a letter of medical necessity from the referring doctor, supporting the physical therapist’s recommendations, further reinforces the need for extended treatment. This letter explains why the prescribed service is necessary for the patient’s condition and potential consequences if treatment is not continued.
Accurate Current Procedural Terminology (CPT) codes used by the physical therapy provider are important, as they must align with the documented medical necessity of services rendered. Prior authorization, or pre-certification, is often required by insurers for additional sessions, even after initial approval. This process involves the provider submitting updated treatment plans and progress notes to the insurer for continued care approval. While the provider typically handles submission, understanding the necessary information helps ensure comprehensive justification.
Appealing Denied or Limited Coverage
When a physical therapy claim is denied or coverage is limited, initiating an appeal challenges the insurer’s decision. The internal appeal process begins by submitting a written appeal letter, though some insurers may accept appeals over the phone or online. The appeal letter should include specific information, such as your name, policy number, the date and reason for denial, and the claim number.
The appeal letter should reference and attach all supporting documentation, including detailed medical records, updated treatment plans, and letters of medical necessity from your doctor. This documentation provides objective support, explaining why the denied service is medically necessary and how it aligns with your policy’s coverage. Insurers typically have specific addresses for appeals; sending the letter via certified mail with a return receipt requested provides proof of submission.
Insurers must respond to internal appeals within specific timeframes. For services already received, a decision is typically made within 60 days; for services not yet rendered, a response is generally within 30 days. Urgent care cases may have an expedited review, with a decision expected within 72 hours. If the internal appeal is unsuccessful, you may be eligible for an independent external review.
The external review process involves an impartial third party, not affiliated with your insurer, reviewing the denial. Your insurer’s final denial letter should provide instructions on how to request an external review, including contact information and deadlines. Documentation for an external review will leverage previously prepared materials, reinforcing the treatment’s medical necessity. Throughout the appeal process, keep detailed records of all communications, submitted documents, and responses, including dates and names.