Ensuring that your insurance will consider your treatment medically necessary is key to avoiding a denied physical therapy claim. Read on to learn what types of physical therapy services fall within this definition.
When is PT Medically Necessary?
Physical therapy, or PT, is considered medically necessary when it is needed to treat an injury or condition and falls within medical standards. Yes, that definition is ambiguous, leaving lots of room for your health insurance provider to find fault with a claim and deny it. While you still may receive a denied physical therapy claim in the following situations, these are examples of medically necessary PT:
- Recovering From Injury. Let’s say you’ve just had a knee replacement and your doctor refers you to a physical therapist for treatment and rehabilitation. Because PT is crucial to improving your condition, it will be considered medically necessary. The same goes for other types of injury rehabilitation services through PT.
- Diagnosing an Injury, Condition, or Disability. If you are referred to a physical therapist to diagnose an injury, condition, or disability, tests and appointments should be covered.
- Physical Therapy That Follows Standard Procedure. Experimental treatments are not classified as medically necessary, so your care must follow standard procedure and practices. (Any treatment that falls beyond your insurance provider’s definition of standard procedure is considered experimental, as are any medical trials your physical therapist might enroll you in). Your PT should warn you if anything they recommend is experimental, but otherwise it can be hard to know as the patient what your insurance might consider non-standard!
- When There Are No Other Viable Alternatives. Your health insurance runs like a business, so their priority is to make and save money. That means a PT claim won’t be deemed medically necessary if there is an alternate treatment plan available that costs less.
Why it Matters
The distinction between medically necessary PT claims and those considered not medically necessary is essential. “Not medically necessary” is one of the most common reasons insurance companies give for denying PT claims. Insurance denied physical therapy claims lead to long appeal battles at best, or responsibility to pay outstanding bills at worst.
Worried about a PT claim denial? Learn how aJust can help!
Get help from experts
We know how complicated this process is. Share your case with us and we will be able to help you.
What to Do if Your Insurance Denies a PT Claim
It is your physical therapist’s responsibility to provide grounds for medical necessity when they are billing your insurance for sessions, which means that much of this is out of your hands. If you received a denied PT claim because the claim lacks proof of medical necessity, there’s not much you can do except reach out to your physical therapist for help proving medical necessity to your insurance and file an appeal.
In some cases, your doctor may have prescribed or recommended a certain number of PT appointments to complete, yet you’re faced with an insurance denial that throws the remaining sessions in question. Suddenly, you’re faced with a choice: either push on and keep scheduling PT sessions that will be denied by your insurance, or risk worsening health issues to avoid an expensive bill. When you’re in that situation, appealing the denial or fighting for a lowered PT bill becomes even more important.
That’s when you want aJust on your side.
Count on aJust to Take on a Physical Therapy Insurance Denial
You know that your PT sessions are important to your medical condition and your physical therapist knows, too. Convincing your insurance company of that, however? Well, it’s not always a straightforward process. aJust knows denials and appeals better than anyone, and understands what it takes to get a PT claim covered. They’ll take over your case and put in the time and effort necessary to get your insurance company to see reason. If that doesn’t work, aJust will do everything possible to lower your physical therapy bill.