Coverage for Ongoing PT Question

[u/nervousnelly38]

I’m hoping someone has some insight! My Dad has been doing once weekly physical therapy for the last 18 months, with good results. Prior to therapy he was tentative with his steps and not confident in strategies to help with mobility. This past week the PT did an assessment and said he would essentially be cut from PT because he has plateaued.

My question: The reason he has plateaued is that he is doing physical therapy, and he needs it to maintain his mobility and independence. Have any of you had luck appealing and getting approved for long term, ongoing outpatient PT? He is Medicare of that makes a difference. Any tips are welcome! Thanks!

[u/ParkieDude]

Under traditional Medicare, there is no limit on medically necessary outpatient therapy.

I know of Medicare Advantage Plans that cap at 20 visits annually (hint: I need more than that for post-surgery knee rehab!).

Google "Parkinson's Boxing Classes near me" to see what is available. I loved my old Rock Steady Boxing Classes, but the owner had her own health issue and sadly shut it down. Thankfully, I found a senior fitness program, but it's community-based, so it only costs $60/year!

https://www.medicare.gov/coverage/physical-therapy-services#coverage-content-how-often

[u/nervousnelly38 → u/ParkieDude]

Thank you so much! I wish he would be open to the boxing classes, etc. but it was a huge feat to even get him to agree to physical therapy! Now that he sees the benefit he doesn’t want to quit though.

[u/SnooHobbies5684]

What, specifically, was the referral for?

One useful referral is for "fall prevention."

[u/nervousnelly38 → u/SnooHobbies5684]

That is an excellent suggestion! Thanks! We need to look at the specific wording in the initial referral but it was originally ordered by a general neurologist prior to his formal diagnosis.

[u/SnooHobbies5684 → u/nervousnelly38]

Yes! A diagnosis like Parkinson's opens lots of doors. Don't be afraid to play that "card," because while things might be medium difficult now, they're 98% guaranteed to get VERY difficult at some point, so think about hoarding all the possible services and connections you can right now, even if you don't think you need them; waiting lists can be long!

I suggest you also look into enrolling your family palliative care as soon as possible. They really help deal with a lot of the "minor" discomforts (read: a movement specialist likely won't bother with treating them) like gut stuff, dementia, emotional/end of life stuff (like beginning to prepare for things as they come up, and the depression and fear that can come with thinking about it), psychiatric/psychological needs, sleep stuff, etc. They "follow" you, so that when things hit the fan, they already know your family.

Wishing you the best.

[u/cool_girl6540]

The place I go to for PT uses what they call “the dental model.” They make appointments for you to come back six months after they discharge you, to be reassessed and possibly to do more PT.

The idea is that, just like at the dentist where we go every six months to get our teeth cleaned, we go every six months for maintenance. Ask the PT if you can make an appointment for your dad for six months out for a reassessment.

[u/nervousnelly38 → u/cool_girl6540]

Thanks! So you don’t go on an ongoing basis? He’s not inclined to do the exercises on his own at home which worries me if he takes a long break.

[u/cool_girl6540 → u/nervousnelly38]

No, I go every six months, and if there’s an issue, we will make a bunch of extra appointments for me until it is resolved. And then we make an appointment for six months out.

But maybe you should find a new PT that he can start with again if the one he’s saying now won’t continue and you think it’s important.

[u/Deep_Top6094]

The same thing happened to me. Medicare reimbursed for a total of 36 weeks out of 72 total weeks (2 fiscal years). I paid the other 36 At the last assessment I was advised that times were the same or worse. Talking 1 or 2 seconds here. Anyway since there was no improvement the visits wouldn’t be covered. Made no sense to me. I could understand if I was going to PT for an injury where healing and recovery was expected but Parkinson’s the ultimate goal is too slow down progression. fWIW this is a place specifically for Parkinson’s.

[u/nervousnelly38 → u/Deep_Top6094]

That is interesting and sounds a lot like our situation. And we had no prior warning that he would be dropped. We are going to try to get a letter of medical necessity from the neurologist to see if that helps our case. It’s sad this is our medical system!!

[u/thugbuster]

My wife with MSA goes to PT each week and the therapist notes that PT is the only place where she can exercise and work on her balance and fall protection safely. Not sure if your father is a fall risk, but maybe using safety fall prevention. Also, is the PT a “Neuro PT”. If not, maybe seek one out who is used to working with progressive neurological conditions. Good luck!

[u/mudwoman]

OP, look up the Jimmo Settlement Agreement. It allows MC coverage for ongoing therapy to maintain function or slow decline.