Humana Physical Therapy Denied? Medicare Advantage Appeal Guide

Physical therapy is a core treatment for recovery from surgery, injury, stroke, and chronic musculoskeletal conditions. When Humana denies physical therapy coverage, it can derail your recovery and leave you with lasting functional limitations. The good news: Humana's Medicare Advantage members have strong legal protections — and many physical therapy denials can be successfully overturned on appeal.

Why Humana Denies Physical Therapy

Humana's Coverage Determination Guidelines and Medical Coverage Policies set the clinical criteria for physical therapy authorization. The most common denial reasons include:

Visit limits exceeded. Humana MA plans often impose annual visit limits on physical therapy that are more restrictive than what Original Medicare would allow. Original Medicare does not have a hard cap on physical therapy visits — it covers PT that is medically necessary. If Humana imposes a stricter limit, that may violate CMS rules requiring MA plans to provide coverage at least as generous as Original Medicare.

Improvement standard applied incorrectly. Humana reviewers sometimes deny continued physical therapy on the grounds that the patient has reached a plateau and is no longer making measurable progress. This is unlawful. The landmark 2013 court settlement in Jimmo v. Sebelius established definitively that Medicare — and therefore Medicare Advantage — does NOT require patients to show improvement to qualify for continued coverage. Maintenance PT to prevent deterioration is covered if it requires the skills of a licensed physical therapist.

Medical necessity not established. Humana may deny PT if the documentation submitted doesn't adequately describe the functional deficits being treated, the specific therapy interventions planned, and the goals of treatment.

Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization not obtained or expired. Humana requires prior authorization for physical therapy, and authorizations have visit or time limits. If care continues after authorization expires, claims are denied.

Level of care disputes. Humana may authorize home physical therapy but dispute a claim for outpatient PT, or vice versa, arguing that the requested setting is not medically appropriate.

Jimmo v. Sebelius: The Rule That Changes Everything

The Jimmo settlement is arguably the most important legal protection for physical therapy patients in Medicare and Medicare Advantage. It establishes that:

1. Coverage does NOT depend on whether the patient is improving.
2. Coverage IS available when skilled PT services are needed to maintain function or slow decline.
3. Humana cannot deny PT solely because a patient has reached a plateau, is disabled, or has a chronic condition.

If Humana's denial letter says anything suggesting that treatment was denied because you are not improving or have plateaued, that is a Jimmo violation. Cite the settlement directly in your appeal: Jimmo v. Sebelius, No. 5:11-cv-17 (D. Vt. 2013), and note that CMS's Medicare Benefit Policy Manual was updated to reflect the maintenance standard.

Humana MA vs. Original Medicare: The Coverage Floor

CMS rules require that Humana Medicare Advantage plans cover all services that Original Medicare covers. Humana cannot impose stricter PT limits than Original Medicare would allow. If Original Medicare would cover your physical therapy — assessed under the skilled care standard, with documentation of medical necessity — Humana must cover it too.

This means:

• No hard annual visit cap that is more restrictive than Original Medicare
• No improvement requirement
• Maintenance therapy for chronic conditions must be covered
• Coverage for PT following Medicare-covered surgeries and hospitalizations

If Humana's MA plan is applying criteria that Original Medicare would not, that is a CMS compliance violation worth raising in your appeal and in a CMS complaint.

How to Appeal a Humana Physical Therapy Denial

Step 1: Read the denial carefully. Identify the specific reason — visit limit, improvement standard, medical necessity, prior auth — and the Humana policy cited.

Step 2: Gather functional outcome documentation. The strongest PT appeals include specific, objective functional measures. Have your physical therapist document using validated tools such as:

• Functional Independence Measure (FIM)
• Timed Up and Go (TUG) test
• 6-Minute Walk Test
• Berg Balance Scale
• Oswestry Disability Index (for back conditions)
• LEFS (Lower Extremity Functional Scale)

Specific numbers — "patient's TUG score is 18 seconds, functional threshold is 12 seconds" — are far more persuasive than narrative descriptions.

Step 3: Get a physician letter. Your treating physician or physical therapist should write a letter explaining:

• The diagnosis and functional deficits
• The specific PT interventions being performed and why skilled care is required
• The treatment goals (including maintenance goals if applicable)
• Why cessation of PT would result in functional decline or medical deterioration
• Citation to Jimmo if Humana denied for lack of improvement

Step 4: File the internal appeal. Submit your appeal to Humana within 60 days (MA plans) or 180 days (commercial plans) of the denial. Include all functional outcome documentation, the physician letter, and your Jimmo/CMS compliance argument.

Step 5: Request peer-to-peer review. Your physical therapist or physician can speak directly with Humana's clinical reviewer. Call 1-877-320-1235 to initiate. Peer-to-peer reviews are particularly effective for PT denials because the conversation allows the provider to explain functional deficits in clinical detail.

Step 6: Escalate to External Independent Review: Complete Guide" class="auto-link">external review. If the internal appeal is denied, request an IRO (Independent Review Organization) review. For Medicare Advantage, proceed to the QIC (Qualified Independent Contractor) review level.

What to Document for a Winning PT Appeal

• Baseline and current functional measurements using standardized tools
• Before-and-after photos or videos of functional tasks if relevant
• Documentation that skilled PT is required (not just exercise)
• History of what happens when PT is discontinued (functional regression)
• Provider attestation that the Jimmo maintenance standard applies
• For MA plans: confirmation that Original Medicare would cover this PT

Fight Back With ClaimBack

ClaimBack generates a professional Humana physical therapy appeal letter citing Jimmo v. Sebelius, CMS MA coverage rules, and the specific functional outcome measures that overturn PT denials. Start your appeal at https://claimback.app/appeal and get your physical therapy coverage reinstated.

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal