How to Get Insurance to Cover Physical Therapy (Including More Visits)

Written by Aptiva Health Editorial Team · Clinically reviewed by Simon Hoehn, DPT, PT · Reviewed by Crystal Brake, RCM Director · Editorial & review standards · How we research

Physical therapy (PT) helps you recover strength, movement and function after an injury, surgery or long-term pain. It often takes many visits. That is where coverage problems start.

Plans may approve only a few visits at a time, cap the number of visits per year, or stop paying when they decide you are no longer improving. This guide explains how PT coverage usually works and how to push back. It is part of the Coverage & Appeals Center.

How plans usually limit PT

Plans control PT in a few common ways. Your plan documents will say which apply to you.

• Visit limits. A yearly cap, such as a set number of visits per year.
• Prior authorization. Approval for the first visits, then re-approval to continue.
• Progress reviews. The plan reviews your therapist’s notes to decide whether more visits are needed.
• Combined limits. Some plans count physical, occupational and speech therapy together.

Read your plan’s summary of benefits for “rehabilitation” or “outpatient therapy.” Ask the plan whether your limit is a hard cap or whether exceptions are possible.

The “improvement standard” and Medicare

Some PT denials say you are “not improving” or have “plateaued.” For people with Medicare, a court settlement known as Jimmo confirms that coverage does not depend on whether you are still improving. Skilled therapy to keep your function or slow decline may also qualify (CMS: Jimmo). This includes Medicare Advantage (CMS FAQ).

The Center for Medicare Advocacy publishes a free self-help packet for outpatient therapy denials that explains this (see Sources).

For private plans, the rules depend on the plan’s own policy.

What your therapist should document

Strong PT notes are the best defense against a denial. Ask your therapist whether your records show:

1. Measurable goals. For example, walking a certain distance or lifting a certain weight.
2. Objective measures. Range of motion, strength scores, or standard function tests, recorded over time.
3. Progress toward goals, or, if progress is slow, why skilled therapy is still needed.
4. Why a licensed therapist is needed, rather than a home program alone.
5. The plan for how many more visits and what they will achieve.

A 2021 appeal manual by Gwen Simons, PT, JD, shared by APTA’s Academy of Orthopaedic Physical Therapy, gives therapists more detail on documentation and commercial plan appeals (AOPT manual, 2021).

How to get more PT visits covered

1. Check your benefit. Find your yearly visit limit and whether prior authorization is needed to continue.
2. Track your visits. Know how many you have used so you can plan ahead of a limit.
3. Ask your therapist to request more visits early. Requests made before you run out avoid gaps in care.
4. Make sure notes show goals and progress. Ask your therapist to include measurable results and the reason more visits are needed.
5. Ask about an exception. If you hit a visit limit, ask the plan whether a medical exception is possible.
6. Appeal a denial. File an internal appeal with your therapist’s letter and progress notes before the deadline.
7. Ask for external review if needed. If the plan upholds the denial, request an outside review.

Sample appeal letter

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Plan name] — Appeals Department
[Address or fax from your denial letter]

RE: Appeal of physical therapy denial
Member name: [Name] · Member ID: [Number]
Claim / reference number: [Number]
Service: Outpatient physical therapy, [number] additional visits
Treating therapist: [Name, credentials]
Ordering clinician: [Name, credentials]
Date of denial: [Date]

To the Appeals Department:

I am appealing your decision to deny [or limit] my physical therapy. Your letter says: "[exact reason]."

Skilled physical therapy remains medically necessary for me:
- My goals are: [goal 1, goal 2].
- My progress so far: [measure at start] → [measure now], see notes from [dates].
- What is still needed: [what therapy will achieve with more visits].
- Why a therapist is needed: [why a home program alone is not enough].

[If "not improving" was the reason:] My therapist explains in the enclosed letter why skilled therapy is needed to [maintain my function / prevent decline].

Enclosed:
- Letter from my physical therapist
- Progress notes and measurements from [dates]
- Referral or order from [clinician]
- Your denial letter

Please approve [number] additional visits. If you uphold the denial, please give me the specific reason, the criteria used, and the steps for external review in writing.

Sincerely,
[Signature]
[Printed name]

Deadlines

Medicare has its own therapy appeal steps (Medicare.gov: Original Medicare appeals; Medicare.gov: Medicare Advantage appeals).

See Kentucky and Indiana for state steps.

What the process looks like

PT coverage often happens in rounds rather than all at once. A common pattern looks like this. Your plan may differ.

1. Your clinician refers you to PT, or you go directly if your plan allows it. Kentucky needs no referral (KRS 327.010); Indiana allows 42 calendar days without one (IC 25-27-1-2.5).
2. Your therapist does an evaluation and sets goals.
3. The plan approves a first set of visits, if prior authorization is required.
4. Your therapist sends progress notes before those visits run out.
5. The plan approves more visits, approves fewer, or denies.
6. If denied, your therapist can ask for a review and you can appeal.

The most important moment is step 4. A request sent early, with clear measurements, avoids gaps in your care.

An example

*This is an illustrative example, not a real patient.*

Jordan is recovering from knee surgery. The plan approved an initial set of visits. When Jordan’s therapist asked for more, the plan denied them, saying Jordan had “reached maximum benefit.”

Jordan’s therapist reviewed the notes. They showed that Jordan’s knee bend had improved, but the notes didn’t say what was still limited or what more therapy would achieve. The therapist wrote a letter with Jordan’s measurements at the start and now, the remaining goals (climbing stairs, returning to work), and how many visits were needed to reach them.

With that, Jordan appealed. The point is the same in most PT denials: the notes need to show what skilled therapy will still achieve.

Questions to ask your therapist’s office

• “How many visits does my plan allow this year, and how many have I used?”
• “Do you need approval to continue? Who requests it, and when?”
• “Do my notes show measurable goals and progress?”
• “If I hit my limit, can we ask for an exception?”
• “What is the cash-pay rate if coverage runs out?”

Common mistakes

• Running out of visits before asking for more. Ask early.
• Notes that say “patient tolerated treatment well” but nothing measurable. Plans look for numbers and goals.
• Mixing up PT benefits. Some plans count physical, occupational and speech therapy together.
• Missing the appeal deadline while waiting for more notes.

What your denial letter should tell you

Since January 1, 2026, Medicare Advantage, Medicaid, CHIP and HealthCare.gov Marketplace plans must give a specific reason when they deny a prior authorization request. A vague reason makes an appeal harder, so it is fair to ask for more detail.

When you get a denial for physical therapy, check that the letter tells you:

• The exact service that was denied and the date.
• The specific reason, in words you can act on.
• The policy or criteria the plan used. If it doesn’t, ask for a free copy (29 CFR 2560.503-1(g)(1)(v)).
• Your deadline to appeal and how to send it.
• How to ask for an expedited review if it’s urgent.
• How to ask for an external review if the internal appeal fails.

If anything is missing, call the plan, ask for it in writing, and write down the date, the name of the person you spoke with, and a reference number.

Costs and your deductible while you wait

An appeal can take weeks. Meanwhile, it helps to understand what you might owe either way.

• If the appeal succeeds, the plan pays under your normal benefits. You still owe any deductible, copay or coinsurance. See how your deductible works.
• If you go ahead before a decision, you may owe the full bill if the appeal fails. Ask for a written cost estimate first.
• Check your EOB when the claim is processed. It shows what was billed, allowed and owed. See how to read your EOB.
• Ask about payment plans if a large bill arrives during the appeal. Ask the billing office to hold the account while the appeal is open.

PT after a work injury or car crash

If your injury happened at work, workers’ compensation usually pays for PT, not your health plan. Workers’ comp has its own rules and appeal steps. If you were hurt in a car crash, your auto policy may pay first.

If coverage doesn’t work out

• Ask for external review.
• Ask about a cash-pay rate for continued visits. See cash-pay and self-pay options.
• Ask your therapist for a home exercise program to keep progress going between visits.