Medicare Denied Physical Therapy — How to Appeal and Get Coverage

Physical therapy helps seniors recover from surgery, manage chronic pain, prevent falls, and maintain independence. Medicare covers it — but denials are common, and they're often based on a misunderstanding of what the law actually requires. If your physical therapy claim was denied, there's important legal protection you need to know about.

What Medicare Covers for Physical Therapy

Medicare Part B covers outpatient physical therapy, occupational therapy, and speech-language pathology services when they are:

• Medically necessary
• Provided by or under the supervision of a licensed therapist
• Part of a plan of care established by a physician or therapist
• Reasonable and necessary for the treatment of your condition

There is a cap-related history that is now resolved: Congress eliminated the therapy spending caps permanently in 2018. This means there is no hard dollar limit on Medicare physical therapy coverage — as long as the therapy continues to be medically necessary.

Medicare also covers inpatient rehabilitation (under Part A) when skilled therapy is needed on an inpatient basis following a hospitalization.

The Jimmo v. Sebelius Ruling: A Critical Distinction

One of the most important legal protections for Medicare PT beneficiaries is the 2013 Jimmo v. Sebelius settlement, which clarified a fundamental coverage rule that Medicare contractors were routinely getting wrong.

Before Jimmo, Medicare claims were often denied based on an unofficial "improvement standard" — the assumption that therapy is only covered if the patient is expected to improve. This led to denials for patients with chronic conditions, neurological diseases, or permanent disabilities, even when therapy was necessary to prevent decline.

The Jimmo settlement made clear: Medicare covers therapy that is necessary to maintain a patient's current condition or prevent further decline, not only therapy aimed at improvement. A patient with Parkinson's disease, multiple sclerosis, post-stroke disability, or severe arthritis may need ongoing maintenance therapy — and Medicare must cover it.

If your PT was denied on the grounds that you weren't "improving" or had "reached a plateau," this is a direct Jimmo violation and should be appealed explicitly on those grounds.

Why Physical Therapy Claims Get Denied

Maintenance therapy denial. As described above, some Medicare contractors still apply an illegal improvement standard. Cite Jimmo v. Sebelius in your appeal.

Medical necessity. The plan or contractor determined that therapy wasn't medically necessary for your condition. Your therapist's documentation of your functional limitations, goals, and treatment plan should address this.

"Custodial care" classification. Medicare does not cover purely custodial services, but physical therapy that maintains function is not custodial — it is skilled care. If your claim was reclassified as custodial, your therapist can document the skilled nature of the services.

Duration or frequency concerns. If the plan questions whether the number of sessions or the frequency of treatment is justified, your therapist can document the clinical rationale for the treatment plan.

Non-participating provider. Therapy from a provider not enrolled in Medicare will generally not be covered by Original Medicare.

How to Appeal a PT Denial

Step 1: Get the denial in writing and identify the reason.

Step 2: Ask your physical therapist to review and document. Request that your therapist write a detailed statement addressing:

• Your functional limitations and baseline status
• Your goals (maintenance of current function, prevention of decline, and/or specific functional improvements)
• Why skilled therapy — rather than home exercise alone — is necessary
• The treatment plan and expected duration

Step 3: Have your physician write a Letter of Medical Necessity. Your doctor's letter should support the therapy's medical necessity and connect the therapy to your diagnosis.

Step 4: File the appeal. For Original Medicare, file a Redetermination within 120 days. For Medicare Advantage, file within 60 days of the denial.

Step 5: Cite Jimmo if applicable. If the denial reason references lack of improvement or reaching a plateau, explicitly reference the Jimmo v. Sebelius settlement and the CMS clarification that Medicare covers maintenance therapy when skilled care is needed.

The Manual Therapy Coverage Issue

Medicare covers services performed by the therapist, but there are ongoing issues with certain manual therapy techniques and treatment modalities. If specific techniques within your PT were denied (rather than the PT overall), ask your therapist to document the clinical evidence supporting those specific interventions for your diagnosis.

Medicare Advantage Prior Authorization Denied: How to Appeal" class="auto-link">Prior Authorization for Therapy

Many Medicare Advantage plans require prior authorization for physical therapy visits beyond an initial number (often 6–12 visits). If your authorization ran out and the plan denied additional visits, your therapist can file for an authorization extension with supporting documentation. If the authorization extension is denied, that denial is itself appealable through the plan's appeals process.

Getting Help

The State Health Insurance Assistance Program (SHIP) can assist with Medicare PT appeals at no cost. Your physical therapist may also be experienced with appeals and can be an active participant in the process.

Fight Back With ClaimBack

Physical therapy is often essential to a senior's ability to remain independent, safe, and active. If your PT claim was denied, ClaimBack can help you build a professional appeal that cites the correct legal standards and includes the documentation that gets results.

Start your appeal at ClaimBack

Related Reading

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