Physical, occupational and speech therapy: 39% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 11–20 Speech therapy · Child health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for speech therapy services five times a week utilizing dynamic temporal and tactile cueing. Per the medical records, the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for speech therapy services five times a week utilizing dynamic temporal and tactile cueing. Per the medical records, the patient’s diagnoses include autism spectrum disorder, receptive-expressive language delay, and articulation disorder. While speech therapy is indicated the improve the patient’s participation, independence, and quality of life, there is a lack of quality research supporting the particular requested modality of dynamic temporal and tactile cueing or the requested intensive frequency of five times weekly. Moreover, there is a lack of research demonstrating that receiving speech therapy in an outpatient setting is more beneficial than in a home or school setting. In this patient’s case, the requested speech therapy modality at the requested frequency level is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, speech therapy services five times a week utilizing dynamic temporal and tactile cueing are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46532

2. Upheld 2025 · Medical necessity · age 65+ Other · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for an additional one (1) day of Community-Based Adult Services (for a total of five (5) days per week). In this case, the patient was hospitalized for an eye injury…

   The physician reviewer found that a patient has requested authorization and coverage for an additional one (1) day of Community-Based Adult Services (for a total of five (5) days per week). In this case, the patient was hospitalized for an eye injury requiring surgery. The patient has been receiving CBAS, including physical and occupational therapies, as well as skilled nursing care. The patient has impaired mobility and function and is at a high risk of falling. The record reflects that the patient requires supervision to stand by assistance for transfers and ambulation, as well as assistance with daily activities of living, including bathing and dressing. The patient may require assistance with mobility and performing daily activities of daily living, as well as for safety. The patient may also benefit from physical and occupational therapy. However, this does not require the intensity of services provided with CBAS. The patient does not require an additional day of skilled nursing oversight for her condition. Assistance with mobility and daily activities of living, as well as therapy services, can be provided in a less acute setting and is not needed five days per week. All told, the requested additional one (1) day of CBAS (for a total of five (5) days per week) is not necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury in the patient. In addition, the requested additional one (1) day of CBAS (for a total of five (5) days per week) is not necessary for the patient to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Therefore, the requested additional one (1) day of CBAS (for a total of five (5) days per week) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46357

3. Upheld 2025 · Medical necessity · age 41–50 Physical therapy · Genetic conditions The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for physical therapy with Muldowney Protocol. One publication regarding treatment options for hypermobile Ehlers-Danlos syndrome…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for physical therapy with Muldowney Protocol. One publication regarding treatment options for hypermobile Ehlers-Danlos syndrome (hEDS) recommends tailored exercise programs focusing on core and extremity muscle strength, proprioception, joint stability, and improved movement patterns, but does not reference the Muldowney Protocol as a recommendation. Per review of the medical records provided, this patient has been diagnosed with hEDS with multiple years of chronic pain. The patient has requested physical therapy with the Muldowney Protocol. The medical literature describes a variety of evidence-based physical therapy modalities for patients with hEDS, including muscle strengthening, proprioceptive training, core stabilization, and individualized therapeutic exercise programs, but does not specifically reference the Muldowney Protocol as supported by a large body of evidence. Overall, there is a lack of independent studies or case reports that establish comparative effectiveness or superiority of the Muldowney Protocol over established, unbranded physical therapy programs. Given these findings, the requested physical therapy with Muldowney Protocol is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46200

4. Upheld 2025 · Medical necessity · age 0–10 Occupational therapy · Autism The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for occupational therapy (OT) and/or an augmentative and alternative communication (AAC) device. In this case, the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for occupational therapy (OT) and/or an augmentative and alternative communication (AAC) device. In this case, the patient underwent a formal OT evaluation, and OT was not recommended. Thus, there is no formal OT evaluation recommending the requested OT services. Further, the patient’s speech therapy progress note indicates that the patient expressed interest in the clinic’s AAC device following the parent’s request to trial a high-tech device. The record also indicates that the patient would benefit from a formal evaluation to determine whether AAC is an appropriate option for expressive language.However, a review of the medical documentation indicates that no formal speech-language evaluation has been completed that demonstrates the medical necessity or appropriateness of the requested AAC device with a recommendation for its use. Therefore, OT and an AAC device are not medically necessary to achieve or maintain age-appropriate growth and development, attain, regain, or maintain functional capacity, or improve, support, or maintain the patient’s current health condition. Final Result: The reviewer determined that the requested service and device are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46164

5. Overturned 2025 · Medical necessity · age 51–64 Physical therapy · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for physical therapy (PT) services. Utilization of postoperative physical therapy is indicated…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for physical therapy (PT) services. Utilization of postoperative physical therapy is indicated following surgical intervention for shoulder pathology, which is evident in this case. According to the literature, patients with rotator cuff tears and scapular dyskinesis can achieve improved shoulder mobility and scapular motion performance with an appropriate rehabilitation program after surgery. Additional studies support that postoperative rehabilitation following rotator cuff repair is important to promote tendon healing, restore strength, and recover normal function. Throughout this patient’s physical therapy sessions, the patient has been noted to be making gains and performing home exercises. Continued skilled therapy is needed to address functional deficits of the upper extremity, including strength and muscular endurance, to support completion of activities of daily living. Furthermore, withholding physical therapy in the postoperative period could lead to further functional deficits of the shoulder. Given these findings, the PT services at issue were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46145

6. Upheld 2025 · Medical necessity · age 41–50 Speech therapy · Autism The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for occupational therapy and speech therapy services. Occupational therapy and speech therapy are standard interventions for…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for occupational therapy and speech therapy services. Occupational therapy and speech therapy are standard interventions for patients with autism spectrum disorder to address communication, functional, and sensory impairments. Continued therapy is indicated when there are ongoing, measurable functional deficits and documented need for skilled intervention. In this case, the patient has a diagnosis of autism spectrum disorder with a history of communication and sensory impairments and has previously received occupational and speech therapy. The medical records indicate that the patient has undergone comprehensive evaluations and that previously identified deficits are no longer reproducible, with documented improvement in functional abilities. In the absence of ongoing, measurable deficits requiring skilled intervention, continued occupational and speech therapy services are not indicated. Based on the available documentation, the requested services are not consistent with accepted standards for continued therapy. Therefore, the requested occupational therapy and speech therapy services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board certified in neurology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-46111

7. Upheld 2025 · Medical necessity · age 41–50 Physical therapy · Brain and nerves The physician reviewer found that a patient has requested authorization and coverage for 12 additional physical therapy visits. Per the medical records, the patient has experienced ongoing neck pain for more than two years following neck surgery. In a…

   The physician reviewer found that a patient has requested authorization and coverage for 12 additional physical therapy visits. Per the medical records, the patient has experienced ongoing neck pain for more than two years following neck surgery. In a systematic review of the effectiveness of physiotherapy and rehabilitation after cervical spinal surgery, the authors noted that reported benefits were concentrated in the early postoperative period; there was no evidence of incremental benefit from very long-term, indefinite physiotherapy, supporting a transition to self-directed exercise. In this clinical setting, the patient has received physical therapy over multiple years for postoperative cervical spine symptoms. Given that the patient has completed the recommended course of therapy, and literature supports the consideration of a structured home exercise program, 12 additional physical therapy visits are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46062

8. Overturned 2025 · Medical necessity · age 0–10 Physical therapy · Teeth The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for orofacial myofunctional therapy.Although there are limited data supporting the utility of orofacial myofunctional…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for orofacial myofunctional therapy.Although there are limited data supporting the utility of orofacial myofunctional therapy, this intervention is medically necessary for the treatment of this patient’s speech regression and retrognathia. Orofacial myofunctional therapy is an approach that focuses on the muscles of the face, mouth, and throat to correct any imbalances or dysfunctions that may affect breathing, swallowing, and speaking. Some research indicates that orofacial myofunctional therapy is beneficial in the pediatric population for enhancing speech sound production. One study noted that there is a growing body of evidence to support the use of orofacial myofunctional therapy within a multidisciplinary team for patients with communication and swallow difficulties. This patient’s retrognathia has functional repercussions, influencing tongue posture and the overall balance of the orofacial muscles. Correcting these dysfunctions with orofacial myofunctional therapy can contribute to better jaw alignment and improve airway function, especially when combined with orthodontic intervention. For these reasons, the requested orofacial myofunctional therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in oral, facial, and maxillary surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45666

9. Overturned 2025 · Medical necessity · age 21–30 Other · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for community-based adult services (CBAS). CBAS is an established level of care that provides structured, non-residential services…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for community-based adult services (CBAS). CBAS is an established level of care that provides structured, non-residential services for individuals with medical, functional, or psychosocial needs requiring ongoing support. Standardized assessment tools are used to determine the appropriate level of care based on factors such as safety risk, functional status, medical and psychiatric comorbidities, and level of support needed. In this case, the patient demonstrates significant needs requiring structured services and ongoing monitoring. The clinical findings support a level of care at least as intensive as the requested services. The requested CBAS services are consistent with generally accepted standards of care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the requested CBAS services are medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested services are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:The reviewer is board-certified in psychiatry and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45553

10. Overturned 2025 · Medical necessity · age 41–50 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for an interdisciplinary day treatment rehabilitation program. Interdisciplinary rehabilitation programs are comprehensive treatment…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for an interdisciplinary day treatment rehabilitation program. Interdisciplinary rehabilitation programs are comprehensive treatment approaches that integrate multiple therapy modalities to improve function, mobility, and quality of life in patients with complex conditions. Clinical evidence supports the effectiveness of such programs in enhancing functional outcomes and promoting independence when ongoing deficits persist despite prior therapy. In this case, the patient has been actively participating in an interdisciplinary rehabilitation program and has demonstrated measurable progress in function and mobility. Continued participation is appropriate to further improve and maintain gains, and the requested frequency and duration are consistent with accepted standards of care. Therefore, the requested interdisciplinary day treatment rehabilitation program is medically necessary for the treatment of this patient. Final Result:The reviewer determined that the service is medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-45545

11. Overturned 2025 · Medical necessity · age 51–64 Physical therapy · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for twelve (12) additional physical therapy sessions. Clinical documentation reflects a history of lower‑extremity injury requiring surgical repair, followed by ongoing…

    The physician reviewer found that a patient has requested authorization and coverage for twelve (12) additional physical therapy sessions. Clinical documentation reflects a history of lower‑extremity injury requiring surgical repair, followed by ongoing physical therapy to restore mobility, strength, and range of motion. Physical therapy is indicated for a tibial plateau fracture with loss of range of joint motion and mobility. The physical therapy documentation supports that the patient continues to make objective progress with therapy in terms of improved range of motion and motor strength as well as improvement in lower extremity functional scale score. The enrollee has also been compliant with prescribed home interventions to support recovery. Overall, 12 additional physical therapy sessions are supported by the medical literature in this patient’s clinical setting. Therefore, the requested twelve (12) additional physical therapy sessions are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-45437

12. Overturned 2025 · Medical necessity · age 0–10 Speech therapy · Child health The physician reviewer found that the parent of a patient has requested reimbursement and prospective authorization and coverage for speech therapy services. In this case, the patient has language delays. Speech therapy is known to be effective to help…

    The physician reviewer found that the parent of a patient has requested reimbursement and prospective authorization and coverage for speech therapy services. In this case, the patient has language delays. Speech therapy is known to be effective to help children with language impairments develop language skills. Speech therapy is known to be effective to help children with language impairments develop functional language skills. To determine the need for speech therapy services, a formal evaluation is needed and must be performed by a speech therapist. The evaluation needs to include a history, observation of behaviors and formal standardized scoring with a validated tool. To be in accordance with standards of care, patients need pre-linguistic skills to benefit from speech therapy services. In this case, the patient underwent evaluation by a speech therapist. The evaluator attempted to perform standardized testing, but the patient could not fully cooperate. The therapist provided an opinion based on the history and observations. The opinion was that the patient would benefit from therapies. This frequency of therapy was in accordance with standards of care at the time of the evaluation. The records include documentation of the initial evaluation and multiple other episodes of delivery of care through the dates in question. Thus, the documentation shows the patient received therapy services throughout this time. Additionally, the literature supports the continued use of speech therapy at the requested frequency in this clinical scenario. In this case, speech therapy services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, speech therapy services were and are medically necessary for the treatment of the patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-45112