Eli's Rehab Report

When a patient's private (not Medicare) insurance plan says 30 therapy visits per year, that's the end of the story, right? Not always. If a patient really needs additional visits to avoid complications, insurance companies can -- and do -- reconsider special cases, says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

What to do: Ask the patient's referring physician if she'll write a letter of medical necessity on behalf of the patient, arguing a case for allowing additional therapy visits. Or, since you, the therapist, are treating the patient and know his needs the best, the letter might have more impact coming from you. See the letter at right, provided by Cobuzzi, as a model.

Re: Jane Doe

DOB: 01-25-1955

ID#: 1234567890

To whom it may concern:

Jane Doe is under my care for a left shoulder injury. She has used 26 of her 30 covered therapy visits to rehabilitate after shoulder surgery. Please consider her case and the possibility of extending the number of her covered therapy visits.

Details: The patient underwent a left shoulder arthroscopy, subacromial decompression/AC joint resection on 12-19-07. She is having a frozen-shoulder reaction from the surgery and needs to continue with physical therapy. She has passive forward flexion of 100, passive abduction of 100, external rotation of 40, and internal rotation to the back pocket.

Her current plan of care is for an aggressive physical therapy and strengthening program to help with her range of motion and strength.

In my opinion, to maximize her recovery, Mrs. Doe needs at least 30 additional sessions of physical therapy to return to her prior level of function. A lack of physical therapy at this juncture will result in postoperative complications and will require additional surgery to correct any problem that will occur.

That said, let me know if you can offer Mrs. Doe additional therapy visits this year to avoid further complications that will jeopardize the patient's health and require more expensive interventions. If you have any questions regarding this matter, please contact my office at 123-456-7890.

Sincerely,

Doctor Smith

Orthopedic Surgeon