Physical Therapy Claim Denied by Insurance: How to Get Your Coverage

Physical therapy is proven to be effective for injury recovery, pain management, and mobility restoration. Yet insurance frequently denies physical therapy claims. The reasons vary—visit limits, medical necessity questions, or timing issues—but many denials are reversible with the right appeal.

This guide explains exactly how to fight back.

Why Insurance Denies Physical Therapy Claims

Understanding the specific reason behind your denial is your first step.

Exceeding Visit Limits

This is the most common PT denial. Many plans allow a set number of PT visits per year (often 20-30). When you exceed the limit, insurance denies further claims. But many denials are premature or unjustified—your condition may require more visits than the standard limit.

Challenge this by arguing:

• Your condition is more complex than anticipated
• You've made progress but aren't yet discharged
• Medical necessity, not policy limits, should determine visit number
• Insurance should approve exceptions for conditions requiring more intensive rehabilitation

Not Medically Necessary

Insurance may deny saying PT isn't medically necessary for your condition. This is often wrong. If your doctor referred you to PT, it's medically necessary. Get your referring physician and PT provider to document this explicitly.

Pre-Authorization Not Obtained

Some plans require pre-authorization before PT. If PT wasn't authorized and you went anyway, insurance may deny the claims. Challenge this by:

• Asking your PT provider to seek pre-auth retroactively
• Showing that you attempted to get authorization
• Arguing that the pre-auth requirement wasn't clearly communicated

PT for Excluded or Limited Diagnosis

Some policies exclude PT for certain conditions or limit it for specific diagnoses. Common exclusions or limits:

• Work-related injuries (covered by workers' comp instead)
• Chronic conditions (insurance may limit PT for ongoing management)
• Pre-existing conditions (if your condition predates the policy)

Challenge exclusions by:

• Showing that the condition didn't actually pre-exist
• Arguing that PT is medically necessary despite the diagnosis
• Showing that the exclusion language is ambiguous and should be interpreted in your favor

Failure to Obtain Physician Referral

Some plans require a physician's referral to physical therapy. If you went to PT without a referral, insurance may deny. If you have a valid reason for starting PT (acute injury, surgeon recommendation, ER discharge), you may be able to get a referral retroactively and fight the denial.

Waiting Period Not Expired

Some plans exclude coverage for certain diagnoses during a waiting period (often 12 months for some conditions). If you're claiming within the waiting period, automatic denial. These are hard to appeal unless you can show exceptional circumstances or that the waiting period shouldn't apply to your specific condition.

Getting Physician and PT Provider Support

Your physicians—both referring MD and physical therapist—are crucial allies.

Contact Your Referring Physician

Call your referring doctor and explain the denial. Ask: "Will you write a letter explaining why physical therapy is medically necessary for my condition? I'm appealing the insurance denial."

Your physician should write:

• Your diagnosis
• Why PT is the appropriate treatment
• Why additional visits are needed (if that's the issue)
• What the expected outcomes are
• What would happen without continued PT (functional decline, prolonged recovery)

For visit limit denials specifically: "This patient requires [X number of visits] rather than the plan's standard limit because [specific clinical reason]. Medical judgment, not policy limits, determines appropriate treatment duration."

Contact Your Physical Therapist

Your PT provider has extensive experience with insurance denials. They can:

• Write a detailed letter documenting medical necessity
• Provide clinical documentation of your progress
• Request pre-authorization retroactively if needed
• Advocate directly to the insurance company
• Help you understand your specific plan's limitations

Ask your PT: "Will you help me appeal this denial? What documentation do you need from me?"

Your PT provider should write:

• Your diagnosis and functional baseline
• PT treatment plan and goals
• Progress to date
• Why additional visits are needed
• Functional outcomes expected with continued treatment
• What would happen if PT stops (plateau, functional decline)

For visit limit denials: "This patient has made excellent progress, but has not yet achieved functional independence. Discharged at this point would result in [specific functional deficit]. Continued PT is medically necessary to achieve treatment goals."

Get Both Medical Voices

A letter from your doctor AND your PT is more powerful than one alone. Both demonstrate medical consensus that PT is necessary.

Understanding Physical Therapy Visit Limits

Visit limits are one of the most common grounds for PT denials. Here's how to challenge them effectively.

What's Standard?

Most insurance plans allow:

• 20-30 PT visits per year, or
• Some define limits per episode of care (post-surgery, per diagnosis)
• Some exclude PT for chronic conditions entirely

Challenging Visit Limits

PT should be determined by medical necessity, not arbitrary policy limits. If your provider determines you need more visits, argue:

"While the plan limits PT visits to [X], my condition requires [X+Y] visits because:

• My condition is more complex than typical
• I have comorbidities that complicate recovery
• My functional goals require extended treatment
• I have achieved measured progress and am on track to further improvement

Medical necessity, not policy limits, should determine appropriate visit frequency."

Requesting an Exception

Many insurers allow "exceptions" to standard visit limits for cases where medical necessity justifies additional treatment. Ask your PT or doctor to request an exception explicitly. Include:

• Documentation that you've made meaningful progress
• Functional measures showing improvement
• Specific clinical reasons why more visits are needed
• Expected timeline to discharge from PT

Building Your Physical Therapy Appeal Letter

Structure your appeal to address insurance's specific stated reason.

Opening

"I am appealing [Insurance]'s denial of coverage for physical therapy visits [specific dates] for my [diagnosis]. Physical therapy is medically necessary for my condition and recovery."

Your Clinical Situation

Describe your injury, surgery, or condition:

• When did it occur?
• What symptoms or functional limitations do you have?
• What functional goals are you working toward in PT?
• What progress have you made so far?

Use specific, concrete examples: "Before PT, I couldn't walk more than 50 feet. I've progressed to walking 500 feet, but still cannot climb stairs independently."

Why PT is Medically Necessary

Explain:

• What your referring physician recommended
• Why PT is the appropriate treatment for your condition
• What outcomes you're expecting
• Why stopping PT now would harm your recovery

Addressing Insurance's Specific Denial Reason

If they said you've exceeded visit limits: "While the plan allows [X] visits, my condition requires [X+Y] visits because [specific clinical reason]. [Doctor/PT] has documented that [reason]. Additional visits are medically necessary."

If they said it's not medically necessary: "Physical therapy is the standard treatment for [condition]. My physician recommended it specifically for my situation. [Doctor] has documented its medical necessity in their letter."

If they said pre-auth wasn't obtained: "I was not aware that pre-authorization was required. [PT provider] is willing to seek pre-auth retroactively. Alternatively, my injury/condition made urgent PT initiation necessary before pre-auth could be obtained."

If they cited an exclusion or waiting period: "My condition did not pre-exist the policy [if true], so the pre-existing exclusion doesn't apply. Alternatively, [reason] requires that treatment be covered despite the exclusion."

Attached Documentation

List all attached documents:

• Your physician's referral for PT
• Your physician's letter supporting medical necessity and additional visits
• PT evaluation report
• PT progress notes showing functional improvement
• PT provider's letter supporting medical necessity of continued treatment
• Your policy documents
• Any clinical guidelines supporting PT for your condition

Closing

"Based on [doctor] and [PT provider]'s clinical determination that continued PT is medically necessary, and based on my documented progress and ongoing functional limitations, I request that [Insurance] reverse this denial and approve coverage for [remaining PT visits/exception for [X additional visits]]."

Timeline: Act Quickly

• PT visit limits often trigger denials immediately when the limit is exceeded—don't wait to appeal
• Standard appeal window is usually 90-180 days from denial
• Some plans allow mid-treatment coverage reviews—use this to request exceptions before you exceed the limit

Ask your PT to request a coverage review during treatment if it looks like you'll exceed the limit. This is often easier than appealing after the fact.

Escalating Beyond Insurance

If insurance denies your appeal:

USA

• Escalate to your state's insurance commissioner
• Request external review by an independent medical reviewer
• Contact your employer's HR department (if employer-based insurance)

Other Countries

• Escalate to your country's financial regulator
• File with your country's ombudsman service
• Consider legal consultation

Getting Help With Your PT Appeal

Physical therapy appeals require specific clinical framing. You need to demonstrate that additional visits are medically necessary based on your specific condition and progress, not just that you want more treatment. Your PT provider's support is critical, but organizing the argument persuasively is what wins appeals.

ClaimBack's AI analyzes your PT denial, helps you frame the medical necessity argument, organizes clinical documentation, and drafts a compelling appeal letter your physicians will support. You review, edit, and submit it—maintaining full control.

Get your free PT appeal analysis →

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims.

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