Physical Therapy Coverage Cut Off: How to Request More Visits and Win Appeals

If you’re here, you probably got one of these messages

• “You’ve reached your visit limit.”
• “Further physical therapy is not medically necessary.”
• “Authorization ended.”
• “Coverage terminated after X visits.”
• “You can continue, but you’ll pay out of pocket.”

When insurance stops paying for physical therapy, it can feel sudden and arbitrary—especially if you are improving, but not “done.” The good news is that many cutoffs are not the final word. Some are caused by missing documentation, a coding mismatch, a misunderstanding of your benefits, or a failure to clearly show why ongoing skilled therapy is still medically necessary.

This guide walks you through a patient-friendly plan to (1) understand why coverage stopped, (2) request an extension that matches what insurers look for, and (3) use internal appeals, external review, and faster escalation pathways to avoid long delays.

Some plans have a set number of visits per year. Others say “X visits, then review,” which is effectively a soft cap. The denial may be triggered automatically after the visit count reaches a threshold—even if continued therapy is reasonable—until more documentation is submitted.

What to do: Ask whether the limit is truly fixed or whether exceptions are possible based on medical necessity. Also ask if additional visits require prior authorization, a new order, or a progress report.

This usually means the insurer does not see enough evidence that continued skilled physical therapy is required, or they think home exercise alone should be enough now. A strong extension request must show:

• clear functional deficits that remain
• measurable progress (or a justified plateau with a plan)
• why skilled therapy is still required (not just “more sessions”)
• what will happen if therapy stops too soon ^[9]

Many plans approve physical therapy in blocks (for example, 6–12 visits) and then require re-authorization with updated documentation.

Insurers commonly deny extensions when notes do not clearly show functional limitations, objective measures, goal progress, or why the therapist’s skilled services are still needed. Medicare guidance, for example, emphasizes progress reporting as part of demonstrating medical necessity. ^[9]

Coverage may stop because:

• the clinic is out of network
• the referring clinician order is missing or expired
• a required referral step was missed
• diagnosis or billing codes do not match the condition being treated
• the plan requires prior authorization, but it was not obtained

Before you appeal, call the insurer and ask for specifics. You want the denial reason in writing, but you also want a “plain English” explanation.

Ask these questions:

1. “Is this denial because I reached a visit limit, because authorization ended, or because you determined it is not medically necessary?”
2. “What exact criteria did you use to make this decision, and can you send me the policy or guideline?” ^[2]
3. “What documents would change the decision?”
4. “Do I need prior authorization to continue, and if so, who must submit it?”
5. “What is the internal appeal deadline, and can this be expedited if my function is worsening?” ^[3]

Tip: Write down the date, representative name, reference number, and the exact language they use. That wording drives how you build your packet.

Strong examples (because they are functional and measurable):

• cannot walk more than X minutes without pain or instability
• cannot climb stairs safely
• cannot return to job duties that require standing/lifting
• cannot dress, bathe, or sleep due to pain and limited motion
• recurrent falls or near-falls
• objective weakness (for example, inability to perform repeated heel raises)

Weak examples:

• “pain is severe” (important, but not enough by itself)
• “therapy helps” (true, but needs objective support)

Your therapist must show why a trained clinician’s skill is needed rather than only a home program. This often includes:

• manual therapy or skilled progression of exercise based on reassessment
• gait training, balance training, neuromuscular re-education
• post-surgical protocols requiring careful progression
• safety concerns that require supervision
• documented adjustments due to setbacks or comorbidities
• the medical necessity rationale documented in progress reports ^[9]

A “complete” extension packet often turns a denial into an approval quickly.

Ask your clinic for a progress report that includes:

• current functional status and limitations
• objective measures (range of motion, strength grading, balance testing, timed functional tests)
• progress toward goals (what improved, what remains)
• why skilled therapy is still required
• the plan for the next block of visits and expected functional outcome ^[9]

If your plan requires re-authorization, insurers often want a formal reevaluation.

This letter should be short and specific:

• diagnosis and relevant findings
• what function is limited
• why continued skilled therapy is needed now
• what risk exists if therapy stops early (loss of function, falls, delayed return to work)
• why additional visits will change the outcome

Depending on your situation, attach:

• operative report and surgeon protocol (post-surgical)
• imaging reports (when relevant)
• recent office visit note documenting ongoing functional impairment
• job duty description (if return-to-work is a key issue)

You are not trying to sound dramatic. You are trying to sound like a “criteria match.”

Use phrases like:

• “Ongoing functional limitation documented with objective measures.”
• “Continued skilled physical therapy is required for safe progression and functional restoration.”
• “Measurable progress has occurred, but goals are not yet met.”
• “Stopping now is likely to cause functional regression / fall risk / delayed return to work.”
• “A new block of visits is requested with clear goals and timelines.”

If the insurer cited “not medically necessary,” your packet must repeatedly bring the focus back to function and skilled need, supported by the progress report. ^[9]

For Medicare Part B outpatient therapy, coverage issues often arise after you cross the annual therapy spending threshold where additional documentation is required. Medicare uses a threshold process that triggers use of a specific modifier and, at higher amounts, may trigger targeted medical review. CMS explains this structure for outpatient therapy services. ^[6]

For 2026, Medicare contractor guidance shows the per-beneficiary threshold amounts where claims may be denied without the required modifier. ^[7] Professional organizations also summarize how the threshold and medical review tiers work. ^[8]

• Ask the clinic if the proper modifier and medical necessity documentation were applied when you crossed the threshold ^{[6, 7]}
• Confirm that your progress reporting supports medical necessity for additional services ^[9]
• If you received a denial, ask for the specific reason code so you know whether it’s a documentation/modifier issue or a different coverage problem

Formal appeals can take time. Try these quicker levers first:

Sometimes the first request was too generic. A stronger progress report and clearer functional deficits can change the decision without a full appeal.

In many systems, the treating clinician or therapist can request a peer-to-peer review with the insurer’s reviewing clinician. This works best when the denial is due to incomplete documentation rather than a true benefit exclusion.

For example, “back pain” alone may be too broad, while “lumbar radiculopathy with functional weakness” (if accurate and documented) may better align with criteria. Do not change diagnoses unless clinically true.

If the insurer refuses to extend therapy after resubmission or peer-to-peer, move to an internal appeal.

Consumer guidance explains that if an insurer refuses to pay for a service, you generally have the right to appeal and the insurer must explain why they denied and how to dispute it. ^[2] When the internal process ends, the insurer must provide a written decision and information about how to request an external review if they still deny. ^[3]

Federal rules also set standards for internal claims and appeals processes and external review pathways for many plans. ^{[4, 5]}

Include:

• your name, policy ID, claim number, denial date
• what was denied (additional physical therapy visits)
• why it meets criteria (functional limitations + skilled need + documented progress)
• list of attached documents
• your request: approve additional visits or authorize a defined block

Attach:

• progress report and reevaluation ^[9]
• medical necessity letter
• relevant physician notes or surgeon protocol
• any prior approval history (if helpful)

If your internal appeal is denied, you may be eligible to request external review, which is handled by an independent reviewer. Healthcare.gov explains that you typically must request external review within four months of receiving the final denial notice, and the insurer must accept the external reviewer’s decision. ^[1]

If your plan’s final internal denial letter does not explain how to request external review, that is a red flag—because consumer guidance notes the final determination should tell you how to take that next step. ^[3]

Sometimes the answer is honestly: “The benefit is exhausted.”

If that happens, you still have options:

Some plans allow exceptions for serious functional limitations, recent surgery, neurologic conditions, or high fall risk.

You can ask your therapist for a transition plan that may include:

• a detailed home exercise plan with progression rules
• fewer in-clinic visits focused on reassessment and progression (instead of high frequency)
• group exercise options if clinically appropriate
• telehealth check-ins if covered
• safety plan if balance/fall risk is present

If the clinic offers a discounted self-pay rate, it may be cheaper than continuing at standard billed charges. If you have out-of-network benefits, you may be able to submit claims yourself (ask the clinic for the documentation needed).

1. Call insurance and identify the denial type: visit limit vs medical necessity vs authorization expired. ^[2]
2. Request the criteria and ask what documents would change the decision. ^[2]
3. Get a progress report that shows function, objective measures, progress, skilled need, and plan. ^[9]
4. Ask the clinician for a short medical necessity letter focused on function and risk of stopping early.
5. Resubmit for authorization or request peer-to-peer.
6. If still denied, file an internal appeal with a one-page cover letter and full packet. ^{[3, 4, 5]}
7. If internal appeal fails, request external review within the allowed timeframe. ^[1]

It depends on your plan. Some plans use a visit count, some use a dollar limit, and some use a “review after X visits” model. Medicare uses an annual threshold process that can require additional documentation beyond a certain level. ^{[6, 7, 8]}

A strong progress report that clearly documents functional limitations, objective measures, progress toward goals, and why continued skilled therapy is medically necessary. Medicare guidance specifically emphasizes progress reporting as part of demonstrating medical necessity. ^[9]

Yes. Consumer guidance describes your right to appeal an insurer’s decision and to pursue independent external review after internal appeal for eligible plans. ^{[2, 1]}

Healthcare.gov states you typically must request external review within four months after receiving the final denial notice. ^[1]

When physical therapy coverage is cut off, the fastest path to extension is usually not arguing louder—it is documenting better. If you can clearly show (1) ongoing functional impairment, (2) the need for skilled therapy, and (3) measurable progress or a justified plan, many denials can be reversed through resubmission, peer-to-peer review, or a well-built appeal packet. If internal appeals fail, external review may offer an independent decision that the insurer must follow. ^{[1, 3]}

References: