Physical Therapy Denied in Texas: How to Appeal

A physical therapy denial from your Texas insurer can feel like hitting a wall — especially when you're in pain and your doctor has clearly recommended treatment. The good news is that Texas law gives you meaningful tools to challenge that decision. This guide walks you through why denials happen and exactly how to appeal them.

Common Reasons PT Is Denied in Texas

Visit limit reached. Texas commercial plans often cap PT coverage at 20 to 60 visits annually. Once that limit is reached, the insurer may refuse to authorize more sessions regardless of medical need. Some plans allow exceptions through a medical necessity review, but you have to ask.

Lack of medical necessity. This is the go-to denial for Texas insurers. A utilization review company — often a third party hired by your insurer — reviews your clinical notes and concludes PT is not necessary, often without contacting your therapist or physician.

Not making progress. If your PT notes show you have plateaued or are not improving on measurable metrics, the insurer may deny continued care on the grounds that further treatment is unlikely to yield functional benefit.

Maintenance therapy exclusion. Texas plans frequently exclude therapy that is designed to maintain your current level of function rather than improve it. This is especially common for patients with chronic conditions like MS, Parkinson's, or post-stroke disability.

Wrong provider or facility. If your PT is out-of-network, or your plan requires a specific referral process that wasn't followed, you can receive a denial that has nothing to do with medical necessity.

Texas Insurance Regulations

Texas regulates commercial insurance through the Texas Department of Insurance (TDI). If your insurer is a fully-insured commercial plan, TDI has jurisdiction over your complaint and appeal rights.

Texas law requires insurers to offer an IROs) Explained" class="auto-link">Independent Review Organization (IRO) process for utilization review denials. After your internal appeal is denied, you have the right to an External Independent Review: Complete Guide" class="auto-link">external review by an independent physician. The IRO decision is binding on the insurer in most cases.

For urgent care, the IRO must issue a decision within three days. For standard appeals, the timeline is 15 business days. This is faster than many states, which can work in your favor when your condition requires ongoing treatment.

Important note for Texas self-funded plans: Many large Texas employers use self-funded ERISA plans that are not regulated by TDI. These plans are governed by federal law, and your appeal rights run through the U.S. Department of Labor. Check your Summary Plan Description to determine whether your plan is fully-insured or self-funded.

The Jimmo v. Sebelius Argument

The 2013 federal settlement in Jimmo v. Sebelius overturned the illegal "improvement standard" for Medicare PT coverage. The court held that Medicare cannot deny skilled therapy solely because a patient is not improving — the proper test is whether skilled care is necessary to maintain function or prevent decline.

While Jimmo is a Medicare case, it is a powerful argument in private insurance appeals as well. If your Texas insurer denied PT because you are in a maintenance phase or not making measurable progress, cite Jimmo in your appeal. Frame your PT as necessary to prevent functional decline, manage a chronic condition, avoid falls, or reduce the risk of surgery.

Your appeal should document specific functional goals — things your PT is helping you maintain: walking without a cane, safely navigating stairs, performing job duties, or dressing independently.

Step-by-Step Appeal Process in Texas

Step 1 — Get the denial letter. Request the written EOB)" class="auto-link">Explanation of Benefits (EOB) or denial letter that includes the specific clinical criteria used. Insurers are required to provide this.

Step 2 — Obtain your records. Pull together your PT treatment notes, physician's referral and clinical orders, and any functional outcome assessments. Your PT can help you document measurable functional limitations and goals.

Step 3 — File an internal appeal. Write an appeal letter that responds directly to the denial reason. Attach a letter of medical necessity from your physician and PT. Reference clinical guidelines from the American Physical Therapy Association (APTA) that support your treatment plan.

Step 4 — Escalate to IRO. If the internal appeal fails, immediately request an IRO through TDI. You can file the request at tdi.texas.gov or call 1-800-252-3439. An independent physician who specializes in your condition will review your case.

Step 5 — File a TDI complaint. A formal complaint puts your insurer on notice and creates a record. TDI takes complaints seriously and contacts the insurer to seek resolution.

Building a Winning Appeal

The strongest Texas PT appeals include:

• A detailed letter of medical necessity from your treating physician and physical therapist
• Functional outcome scores (e.g., Lower Extremity Functional Scale, QuickDASH) showing your current deficits
• A description of what will happen if PT stops — increased pain, risk of falls, loss of independence, likely surgery
• Reference to APTA clinical practice guidelines for your diagnosis
• A Jimmo-based argument if maintenance care is at issue

Reviewers respond to specifics. Instead of "patient needs PT," show that "patient currently cannot climb stairs without handrail assistance and is at high fall risk as measured by Berg Balance Scale score of 38. Continued PT is medically necessary to prevent emergency hospitalization."

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Related Reading:

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