As a physical therapist, one of the most important conversations I have with patients is about whether their treatment qualifies as medically necessary. This phrase is central to how insurers evaluate claims, especially for treatments needed after an accident.. The Dubin Law Group staff explains that it determines whether a patient receives coverage for rehabilitation or must pay out-of-pocket. Understanding how insurance companies define medical necessity—and how we document it in practice—can make the difference between consistent care and treatment interruption.
What Medical Necessity Means in Rehabilitation
The Clinical Definition
In physical therapy, medical necessity refers to services that are essential for restoring or improving function after an injury, illness, or surgery. It is not about patient preference or general wellness. Instead, therapy must be directly tied to a diagnosed medical condition and aimed at measurable, functional outcomes.
How Criteria Apply in Practice
Insurers typically look for:
- Specific Diagnosis. For example, therapy following an ACL reconstruction, a total knee replacement, or a stroke is more likely to meet criteria than therapy requested for generalized fitness.
- Functional Goals. A plan of care might target regaining the ability to climb stairs, improving gait mechanics, or restoring shoulder strength sufficient for overhead activities.
- Evidence-Based Care. Interventions must follow accepted clinical guidelines. For example, progressive loading after rotator cuff repair is supported by research, while prolonged passive modalities without progress are not.
- Appropriateness of Care. Insurers expect the least intensive but effective intervention. Manual therapy and therapeutic exercise with documented gains are generally approved, while maintenance-level care without improvement may be denied.
How Insurers Evaluate Claims
Documentation Standards
From an insurer’s perspective, documentation is the most essential proof of necessity. A complete record includes:
- Physician referral with diagnosis
- Initial evaluation with objective measures such as range of motion, manual muscle testing, or standardized scales (for example, the Berg Balance Scale after stroke)
- A plan of care with specific, time-bound goals
- Progress notes showing functional improvement, such as increased walking distance or reduced pain during daily tasks
When these elements are missing, even clinically appropriate therapy can be denied.
Cost and Outcome Review
Insurers assess whether the therapy provides measurable benefit relative to cost. For instance, continued electrical stimulation without functional change is often denied. On the other hand, progressive strengthening with documented gains in mobility usually passes review.
Risks of Denial
Financial Burden
Without insurance approval, patients may face hundreds of dollars per week in therapy bills. Given that recovery from surgeries such as joint replacements or spinal procedures may require 12 weeks or more of therapy, the costs can escalate quickly.
Clinical Consequences
Gaps in care can have long-term effects. A patient who discontinues therapy after a knee replacement may experience stiffness, reduced walking ability, or permanent loss of function. Similarly, stroke survivors who stop therapy too early may fail to regain independence in activities of daily living.
What To Do if Your Therapy Is Denied
- Review the Explanation of Benefits (EOB). This document specifies the reasons why the claim was denied, often citing a lack of medical necessity or insufficient documentation.
- Collaborate With Your Therapist. We can update notes, add outcome measures, or provide physician progress reports that demonstrate clinical necessity.
- Appeal the Decision. Most insurers allow appeals, and a well-supported submission—including objective progress data, such as improved six-minute walk test results or gains in strength—often succeeds.
Final Perspective
For patients and clients of Dubin Law Group, understanding the term ‘medically necessary‘ is crucial. For providers, documenting necessity is part of clinical responsibility. Physical therapy must be targeted, evidence-based, and tied to measurable goals to receive insurance approval. With accurate documentation and clear communication, patients are more likely to obtain the necessary coverage to achieve a safe and complete recovery.