When Should Medicare Coverage be Available for Outpatient Therapy?
Physical, speech-language pathology, and occupational therapies can be covered by Medicare Part B if they meet the following criteria:
- The patient’s physician or authorized health care provider orders and periodically reviews the patient’s therapy regimen.
- The therapy is “medically necessary.” This means that the therapy provided is considered a specific and effective treatment for the patient’s condition under accepted standards of medical practice.
- The therapy required can be safely and effectively performed only by, or under the supervision of, a qualified therapist because of the complexity of the therapy or medical condition of the patient.
Other Important Points:
- Too often, Medicare denials are based on a belief that the patient’s medical condition will not significantly improve. However, “restoration potential” is notrequired under the law. Therapy to maintain an individual’s condition or slow deterioration can be coveredif a skilled professional is necessary to provide or supervise the care.
- Therapy that can ordinarily be performed by a nonskilled person can be covered by Medicare if the patient’s condition is so medically complex that it requires a skilled therapist to perform or supervise the care.
- There is no longer a cap on the amount of therapy Medicare will cover each year. The definite limit on therapy was repealed in 2018. Instead, providers must use a certain code to bill Medicare for therapy and, since 2022, Medicare can perform a special review on claims over $3,000 for physical therapy and speech-language therapy combined and for occupational therapy.
- Review all Medicare notices to learn why Medicare coverage is being denied. If an appeal is appropriate, follow the directions on the notice regarding how to appeal. Send a letter with the appeal explaining why the therapy was medically necessary. If possible, attach a supportive letter from the patient’s physician and therapists.