Services Not Considered Medically Necessary

Medicaid requires physical therapy to demonstrate measurable functional progress to be covered. The following services are not reimbursable:

• Maintenance therapy that does not show measurable improvement

• Therapy without a clear treatment plan or supporting clinical documentation

• Recreational, social, or educational therapy

• Exercises that can be performed independently without skilled guidance

• General fitness, wellness, or conditioning programs

These services are considered non-medical and are only available as self-pay options.

Documentation & Billing Restrictions

To be covered by Medicaid, physical therapy services must meet specific documentation and billing requirements. The following are not reimbursable:

• Services provided without a referral from a licensed healthcare provider (LPHA) such as a physician, APRN, or PA

• Treatment rendered before obtaining consent or required documentation

• Duplicate billing for services already provided by another provider

• Charges for missed appointments or canceled sessions (Medicaid does not reimburse for no-shows)

• Group therapy sessions exceeding 6 students (Medicaid enforces a limit)

• Telehealth services billed for group therapy (Medicaid only covers individual telehealth sessions)

Provider & Supervision Requirements

Medicaid only reimburses physical therapy services when performed by qualified providers in approved settings. The following provider-related exclusions apply:

• Unlicensed or unsupervised therapy (e.g., PTA working without PT oversight)

• PTAs conducting evaluations or writing treatment plans (only licensed PTs may do so)

• Services provided outside the South Carolina Medicaid Service Area (SCMSA)

If a provider does not meet these requirements, Medicaid will not reimburse the services.

Service Setting & Treatment Modality Exclusions

Physical therapy must be provided in Medicaid-approved settings to qualify for reimbursement. The following are not covered:

• Therapy provided in non-approved locations such as gyms or community centers

• Experimental, investigational, or unproven treatments

• Therapy services that duplicate treatment already billed by another provider (such as overlapping school and outpatient therapy)

Specific Treatment & Equipment Exclusions

Certain treatment techniques and equipment are not considered medically necessary by Medicaid, including:

• Massage therapy, unless part of a skilled intervention

• Acupuncture, dry needling, or cupping therapy

• Use of non-medically necessary exercise equipment, such as treadmills or weights for general fitness

• Orthotic or prosthetic fitting services, unless specifically authorized under Medicaid DME policies

These treatments are available for self-pay at $40 per service but are not eligible for Medicaid reimbursement.

What Does "Medical Necessity" Mean?

Medicaid defines medical necessity as treatments that are essential for improving function, treating a medical condition, or preventing further decline. A service is considered medically necessary if it meets these criteria:

✔ Addresses a specific medical condition, injury, or functional limitation
✔ Is proven effective through research and clinical guidelines
✔ Requires the expertise of a licensed physical therapist (not something that can be done independently)
✔ Has measurable goals for improvement
✔ Demonstrates progress over time

If a service does not meet these criteria, Medicaid will not cover it, even if it may be helpful.

Final Takeaways

• Medicaid restrictions are set by the insurance provider, not by this clinic

• Self-pay rate is $40 per service for any non-covered treatment

• All therapy must demonstrate measurable progress to qualify for coverage

• Duplicate services, non-approved settings, and general wellness treatments are not covered

• If you have questions about your Medicaid plan, contact Medicaid directly for details on your specific policy