Denied Physical Therapy Appeals: Outcomes

Physical therapy evaluation and treatment billed by the treating clinician, reviewed against visit allowances, progress requirements and the plan's definition of skilled care.

What the independent reviewers decided

21%

overturned by the independent reviewer

of 139 decisions in the corpus

Source

California DMHC independent medical review determinations, 2017-2026. Public record.

Read this as a base rate, not as your odds

These are decisions about other patients, in one state, that had already been through the plan's own internal appeal and were then sent to an outside reviewer. That population is self-selected toward disputes worth pursuing, so the rate says what happened to cases like this at that stage — not what will happen to a specific claim. It is not medical or legal advice.

Why plans deny physical therapy

The benefit-year visit allowance has been exhausted.
The record is read as showing a plateau, and the policy covers only care expected to produce measurable gain.
The activities described are classed as a maintenance or home programme rather than skilled therapy.
The plan of care lacks measurable goals and objective baselines.

What actually carried the cases that won

Prior treatment appeared in 86% of the reversals and functional impact in 66% — the two together describe a record that shows a history and a consequence, not a schedule of visits. The decisions that stood tended to rest on notes recording attendance and exercises performed. Peer-reviewed literature was cited in 59% of the reversals, far ahead of clinical guidelines, so a citation tying this protocol to this condition is arguing on the reviewers' preferred ground.

What the record showed	Share of overturned decisions
Prior treatment was documented	86%
The functional impact on the patient was documented	66%
A published guideline supported the request	31%
The condition was documented as chronic or long-standing	28%
The severity or urgency was documented	21%
The diagnosis was confirmed	17%
Objective findings were documented	10%
Conservative treatment was documented as failed	10%

Shares are of the overturned decisions and do not sum to 100% — a single decision often rested on more than one, and some rested on none of these.

What the reviewers cited

Peer-reviewed literature — in 59% of the overturned decisions
Clinical guidelines — in 7% of the overturned decisions
Specialty-society criteria — in 7% of the overturned decisions
Standard of care — in 7% of the overturned decisions

physical therapy denials — frequently asked

Is a denied physical therapy claim worth appealing?

The plan's position held four times in five here: 110 of 139 California determinations were upheld and only 29 reversed. Only inpatient admission fared worse in this corpus. A practice should know that before committing the effort, and should know what the successful fifth contained.

What separated the reversals?

History and consequence. Prior treatment in 86% and functional impact in 66%: what had already been tried, and what the patient still cannot do. Visit notes that record exercises performed do not establish either.

How is a maintenance characterisation answered?

By showing the skill the care requires — the assessment, the progression, the clinical judgement applied between visits — and a measured change over the period the plan is disputing.

Source

California Department of Managed Health Care — independent medical review determinations

Denial reasons and criteria are described in plain language for reference and vary by plan and policy. This page reports what independent reviewers decided in a public California dataset; it is general information, not medical, legal, or coverage advice.

When the appeal has to be written, and cited

Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.

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