Things to Consider when Filing a Physical Therapy Appeal

Things to Consider when Filing a Physical Therapy Appeal

In the months since we filed that External Appeal where they claimed my 8 month pregnant wife had hit maximum function, I’ve had a lot of thoughts on how things could have gone better. As I wrote elsewhere on this blog, my wife is now improving a lot. We are going to a new physical therapist (and occupational therapist), and I’m seeing some differences. In addition to the tips I provided in 9 Tips to Ensure Your Insurer Pays Up, here’s what I’ve learned specific to physical therapy, starting with even before notes are ever sent to the insurance company:

  • There needs to be an OBJECTIVE evaluation done at the beginning, with a plan, and later on, showing improvement. When my wife was pregnant, they chose not to do an evaluation because she was pregnant. However, nowhere in the notes did they say that, which was viewed negatively.
  • Along with the physical therapy notes, doctor’s notes should be sent. The more the merrier if they are your favor. Based on our experience, and some conversations other have had with Aetna, I don’t think the folks there even read the appeals. They only look at the notes, and they choose the specialty matching based on those notes. I wish that when the notes were sent by the physical therapist, we had paid to get records from my wife’s neurologist and OB / GYN, and had them sent too. It would have raised the bar for the specialty matching.

If you are denied, in your appeal, try the following:

  • If you are denied, before you appeal, call them up and ask for all the information mentioned at the beginning of Tip #4. If you do not hear something within a week, send it writing and follow Tip #6. If you don’t hear anything in 30 days, the rules are fuzzy, but they might owe you $110 a day (you’ll need to speak to an attorney about that). Then send them another letter, also following Tip #6.
  • Get a note in writing from as specialized of a doctor as you can outlining your treatment plan. The rules on appeals require that the insurance medical director be a “clinical peer” of the doctor treating the condition.
  • Make sure your appeal includes everything from Tip #4.
  • In your appeal, include the medical records again, or the first time if you had not already. You may have to pay to get them from your physician. What I learned talking to the physical therapist at Aetna who denied us, is that Aetna doesn’t ask for all the notes, and then denies it based on the notes being incomplete. If that is true, you can address that situation by getting and sending everything yourself
  • Use the word “regain function” and “restoration of function” in your appeal. Hopefully your physical therapist and doctor used it in their notes, and did not use words like “maintained.”
  • Please let me know about your progress, by clicking on the About tab above and sending me an E-mail..
  • Make sure to read 9 Tips to Ensure Your Insurer Pays Up

Make sure to “Like” this page if you find this page helpful