How long does insurance cover physical therapy?

This may be one of the most common questions asked when someone is coming to physical therapy. This question is not a one size fits all answer and can vary person to person and insurance plan to insurance plan. 

Some insurance plans require prior authorization for physical therapy. Usually, when this is the case, the authorization is good for a certain number of visits and/or a certain date range. Your therapist will perform your initial evaluation and submit their documentation along with your diagnosis to your insurance company. The insurance company will then determine how many visits you will initially be allowed. Some insurance companies will allow therapists to provide additional information to request additional visits. The therapist must submit documentation that demonstrates that skilled services are being provided, that there are goals that are able to be met, and that there is progress being made towards these goals. Insurance companies may not allow additional visits despite your therapist's request and documentation. 

There are some insurance companies that do not require prior authorization or limit the amount of therapy visits within a calendar year. In this case, your therapist will work with you to set individualized goals and document your progress towards achieving them. It is at your therapist’s discretion and expertise to determine an appropriate length of treatment. The insurance company entrusts that the therapists make appropriate and ethical decisions regarding the number of visits. 

What skill is the therapist providing and why is it important to demonstrate the need for “skilled therapy services?” 

Due to increased scrutiny from insurance companies and reductions in reimbursement, therapists must be able to document and show what skilled services are being provided to their patients and why these services are “medically necessary.” These skilled services require specific skills and training ( i.e. the training, degrees, and licensing for a Physical, Occupational or Speech therapist). Services must be goal oriented with interventions designed to achieve personalized goals with measurable outcomes. Therapists must adjust and modify these interventions to allow for a greater or lesser challenge depending on the patient’s abilities, all while helping the patient to achieve individualized goals that focus on regaining or improving their ability to perform every day activities. If the therapist’s specific training and expertise are no longer required or if progress toward goals has plateaued, therapy is no longer considered “medically necessary.” Centers for Medicare and Medicaid services state that therapy services “should not be repetitive, palliative, or simply reinforcing previously learned skills or maintaining function.” They also state “it is expected that the patient’s treatment goals and achievements during the therapy episode will reflect significant and timely progress.” (learn more here:

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52775) To summarize, the role of therapy is to educate you and help you improve your function so you can continue to follow the therapist’s recommendations and exercises independently to maintain the progress you made in therapy. 

At what point does therapy become "maintenance" ? 

In Wisconsin, the definition of maintenance physical therapy is outlined in the Wisconsin Administrative Code, specifically in DHS 101.03(128)

Maintenance therapy is often initiated when skilled therapy is no longer indicated or the patient’s progress has plateaued. Maintenance therapy helps patients maintain a certain level of lifestyle and avoid a decline in health and ability, rather than making gains through therapy sessions. This type of therapy is often difficult to get covered or is not covered at all by insurance companies. 

What options do I have if my insurance does not cover my therapy? 

If you are looking to continue with achieving your goals, but for one reason or another your insurance company will no longer cover your therapy- there are options out there for you!

 Many people often try to have their physician write an additional referral for therapy- this is not always a solution to getting more visits approved. If you are requesting an additional prescription for the same condition within a short period of time, your insurance company will likely not cover additional visits. If you are seeking a referral for a new condition or a relapse in your current condition, then a new referral may be indicated and warrant additional coverage. 

You may want to consider private pay for therapy or wellness services. Private pay therapy options may be indicated if you are still looking to seek skilled therapy services and

have achievable goals to progress towards. Each clinic determines their private pay prices based on a variety of factors including the therapist's expertise and training, cost to the clinic, and current insurance reimbursement rates. Wellness services are appropriate for those seeking "maintenance" therapy and are designed to help you continue to perform regular exercise and activities to avoid losing the progress you made in therapy or to maintain your current level of function. Therapists will safely guide you through exercise and assist you as needed. Wellness visits can provide accountability and help you stick to the exercise plan your therapist recommended when you completed therapy. These costs are also based on the clinician’s expertise, training etc.