Orlando Harmon
When it comes to insurance coverage for physical therapy, the determination of medical necessity is crucial. Most insurers, including private insurance companies and Medicare, will generally cover physical therapy when it is deemed medically necessary. However, the specific definition of medical necessity can vary, and insurers may have different criteria for determining whether physical therapy is medically necessary for a particular individual. In some cases, a letter of medical necessity (LOMN) from a healthcare provider may be required to improve the odds of reimbursement, but it is not a guarantee of approval. Ultimately, it is up to the individual's doctor or healthcare provider to determine if physical therapy is a medical necessity for their treatment plan.
| Characteristics | Values |
|---|---|
| Who determines if physical therapy is a medical necessity? | A doctor or healthcare provider |
| Who writes and signs a letter of medical necessity? | A healthcare provider |
| Who can write an LOMN? | Chiropractors, nurses, physicians, physical therapists, occupational therapists, psychiatrists, psychologists |
| When is physical therapy considered medically necessary by Aetna? | When prescribed by a chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical therapy |
| When is physical therapy not considered medically necessary by Aetna? | In asymptomatic persons, in persons without an identifiable clinical condition, in persons whose condition is neither regressing nor improving, when a home exercise program could be used for further gains |
| When is physical therapy considered medically necessary by Aetna in the transition from hospital to home? | When it is an extension of case management services |
| When is physical therapy considered experimental, investigational, or unproven by Aetna? | When the effectiveness of approaches has not been established |
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What You'll Learn
- A letter of medical necessity (LOMN) may be required for insurance coverage
- Doctors decide if physical therapy is a medical necessity
- Medicare Part B covers physical therapy deemed medically necessary
- Insurers may require a referral or approval before receiving care
- Some physical therapy treatments are considered experimental
A letter of medical necessity (LOMN) may be required for insurance coverage
A letter of medical necessity (LOMN) is typically written and signed by a healthcare provider, such as a physician, nurse, or physical therapist, to explain the medical necessity of a specific treatment or product. This letter can be submitted to an insurance company or used for reimbursement from a health savings account (HSA) or flexible spending account (FSA). While it does not guarantee approval, it can improve the chances of reimbursement.
When it comes to physical therapy, insurers, including private insurance companies and Medicare, will often help pay for it when it is deemed "medically necessary". However, the extent of coverage can vary. For example, some insurance plans may require a referral or approval before you can receive physical therapy treatment, and there may be limits to the number of sessions covered within a specific period.
In the case of Medicare Part B, individuals are responsible for paying 20% of the Medicare-approved amount after meeting the annual deductible of $240, while Medicare covers the remaining 80%. There is no limit to the number of medically necessary outpatient therapy sessions covered by Medicare in a calendar year. Once individuals reach the eligible expense threshold, they need to provide documentation to prove the ongoing medical necessity of the services.
To confirm coverage for physical therapy, it is recommended to contact the insurance provider directly. They may provide specific templates or requirements for submitting a letter of medical necessity. This letter should include relevant patient history and information about the medical necessity and expected duration of the recommended treatment. It is important to note that the healthcare provider writing the LOMN must be the individual's treating provider.
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Doctors decide if physical therapy is a medical necessity
Doctors or other healthcare providers, including nurse practitioners, clinical nurse specialists, and physician assistants, decide whether physical therapy is a medical necessity. They certify that a patient needs physical therapy, which helps restore or improve physical movement in the body after an injury, illness, or surgery. There is no limit to how much Medicare pays for medically necessary outpatient physical therapy services in a calendar year.
If a patient needs more services than Medicare covers or recommends services that Medicare doesn't cover, they may have to pay some or all of the costs. It is important to ask questions and understand why a doctor is recommending certain services and whether Medicare will pay for them.
To determine the medical necessity of continued therapy services, knowledge of the natural history of diseases requiring therapy, familiarity with alternative treatments, and awareness of community practice patterns are required. Accurate and complete documentation from the therapist or referring physician is essential for a physician advisor or utilization review consultant to make an accurate determination of medical necessity.
A letter of medical necessity (LOMN) is often required for medical procedures or products excluded from health insurance coverage. It is written and signed by a healthcare provider, such as a chiropractor, nurse, physician, physical therapist, or psychiatrist, who is treating the patient. The letter includes relevant patient history and information about the medical necessity and duration of the recommended treatment. While an LOMN can improve the odds of reimbursement, it does not guarantee expense approval.
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Medicare Part B covers physical therapy deemed medically necessary
Medicare Part B covers physical therapy that is deemed medically necessary. Original Medicare (Parts A and B) is a fee-for-service health insurance programme available to Americans aged 65 and older and some individuals with disabilities. It is provided by the federal government.
Medicare Part B covers medically necessary outpatient physical therapy services. Once you meet the Part B deductible, you pay 20% of the Medicare-approved amount. There is no limit to how much Medicare pays for medically necessary outpatient therapy services in a calendar year. However, your doctor or healthcare provider may recommend services that are not covered by Medicare, in which case you may have to pay some or all of the costs.
To obtain coverage, a person must meet their Part B deductible before Medicare funds any outpatient physical therapy. For 2025, the Part B deductible is $257. After this, you will pay 20% of the remaining cost.
Medicare Part B requires that physical therapy is certified as medically necessary by your doctor. This means a referral to a specialist to help with general fitness probably won't be covered by Medicare. Generally, physical therapy must improve or maintain a health condition or keep it from deteriorating.
A letter of medical necessity (LOMN) is usually required for medical procedures or products that are excluded from health insurance coverage. This letter is written and signed by a healthcare provider and can help improve the odds of reimbursement for a product or service, but it does not guarantee approval.
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Insurers may require a referral or approval before receiving care
When it comes to physical therapy, insurers, including private insurance companies and Medicare, will often help pay for treatment when it is deemed "medically necessary". However, it's important to note that the extent of coverage can vary. To confirm your coverage, it is recommended to contact your insurance provider directly. The number of physical therapy sessions covered by insurance can vary based on your specific insurer and plan. Some insurers may require you to use one of their contracted physical therapists, and there may be limits to the number of PT visits allowed within a specific time frame.
In some cases, insurers may require a referral or approval before you can receive physical therapy treatment. This can depend on the specific insurance plan and its requirements. Some plans may permit self-referral, known as "direct access", while others may mandate a provider referral. It is important to check with your insurance provider to understand their specific requirements and guidelines.
If you have Medicare, there is generally no limit to the number of physical therapy sessions you can attend in a year. However, you will need to meet your deductible, after which you will typically pay a percentage of the Medicare-approved amount for each session. It's important to note that Medicare will only cover physical therapy that is considered medically necessary. If your condition does not require physical therapy, Medicare may not provide reimbursement.
To improve the odds of reimbursement for physical therapy, your healthcare provider may write and sign a letter of medical necessity (LOMN). This letter explains why your healthcare provider is recommending physical therapy and includes relevant patient history and information about the expected duration of treatment. While an LOMN can enhance the likelihood of reimbursement, it does not guarantee that the expense will be approved. It is always a good idea to check with your insurance company to understand their specific requirements and preferences for LOMNs.
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Some physical therapy treatments are considered experimental
Physical therapy, also known as physiotherapy, may include exercises, massages, and various treatments based on physical stimuli (e.g. heat, cold, electrical currents, or ultrasound). The aim of physical therapy is to relieve pain, improve mobility, and strengthen weakened muscles. Physical therapy treatments are carried out by specially trained physical therapists or physiotherapists.
While physical therapy is a well-established practice, some physical therapy treatments are considered experimental. This is because, historically, there was little distinction between experimentation and therapy, and most therapy was experimental. Experimental therapies were often used to try to benefit ill patients, but they frequently contributed to or even caused morbidity or mortality.
Today, clinical interventions are typically classified as either established treatments, innovative therapies, or research procedures. While the aim of medical treatment is to care for each patient's best interests, medical research is undertaken to produce new information and knowledge for the collective benefit of future patients. Advances in surgical therapy, for example, can be considered a form of research, as the outcome could benefit future patients and educate doctors.
Some examples of more experimental physical therapy treatments include light therapy and kinesiology taping, or K-tape. Light therapy uses light at a specific wavelength to improve the healing process of injured tissues. The treatment is painless and can be used to treat chronic pain, inflammation, or to speed up wound healing. K-tape is often used by physical therapists to augment a patient's rehab program.
In some cases, a doctor or healthcare provider may recommend physical therapy treatments that are not covered by insurance. In these cases, a patient may need to pay some or all of the costs. A letter of medical necessity (LOMN) from a healthcare provider can help improve the odds of reimbursement, but it does not guarantee that an expense will be approved.
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Frequently asked questions
A letter of medical necessity (LOMN) is a letter from your healthcare provider explaining why a specific treatment or product is necessary for your health. It can help improve the odds of reimbursement for a product or service, but it doesn't guarantee approval.
You may need an LOMN when seeking reimbursement for a procedure, product, or device from your health insurance company, health savings account (HSA), or flexible spending account (FSA). You may also need an LOMN for medical procedures or products that are excluded from health insurance coverage or are not considered qualified medical expenses by the IRS.
The criteria for medical necessity for physical therapy can vary depending on the insurance provider. Generally, physical therapy is considered medically necessary when it is prescribed by a qualified healthcare professional to improve, develop, or restore physical functions lost or impaired due to a disease, injury, or surgical procedure. The specific treatment plan should also include objective and subjective data to demonstrate its medical necessity.
