Non-Covered Services Under Medicare Part B for Outpatient Physical Therapy
Understanding Medicare Coverage
Medicare Part B covers only medically necessary therapy services that:
Require skilled intervention by a licensed therapist.
Are provided under a valid physician/NPP-certified Plan of Care (POC).
Show functional improvement or are needed for skilled maintenance to prevent decline.
If a service does not meet these criteria, Medicare will not cover it. These coverage rules are set by Medicare, not by this clinic. If you wish to receive a non-covered service, you may choose to pay out-of-pocket at $40 per service, which can be added to your session.
Medicare Insurance: Non-Covered Physical Therapy ServicesMedicare-Covered Skilled Maintenance Therapy
Medicare does cover maintenance therapy as long as it meets the following criteria:
A skilled physical therapist is required to maintain function or prevent deterioration.
The patient’s condition would worsen without skilled intervention.
Skilled monitoring, reassessment, or modifications to treatment are required.
💡 Example: If a patient with Parkinson’s disease needs therapist-guided exercises to maintain balance and mobility, Medicare will cover it. However, if the patient is performing a routine home exercise program independently, it is not covered.
Services That Do Not Require Skilled Therapy
Medicare does not cover therapy that can be safely performed without a licensed therapist’s expertise. This includes:
General fitness & wellness programs, such as stretching, strengthening, or gym exercises.
Passive range of motion (PROM) exercises performed without the need for therapist assessment or modification.
Repetitive exercises that do not require therapist adjustments, monitoring, or clinical decision-making.
Routine ambulation programs without a skilled therapist ensuring safety or gait correction.
Supervision of exercises without active therapist intervention.
Group therapy where all patients follow the same routine without individualized modifications.
💡 Example: If a patient recovering from knee replacement is performing stationary biking without therapist adjustments, Medicare will not cover the session.
Services Provided Without a Valid Plan of Care
Medicare requires that all therapy services be provided under a physician/NPP-certified Plan of Care (POC). Services not meeting this requirement include:
Therapy without an initial evaluation or a written POC.
Therapy that exceeds the certified duration without an updated plan.
Treatments that require modifications but were not updated in the POC.
Services provided without physician certification of medical necessity.
💡 Example: If a therapist continues treatment after the POC expires without obtaining recertification, Medicare will deny payment.
Services That Are Not Medically Necessary
Medicare does not cover therapy that lacks medical necessity or functional benefit, including:
Therapy provided for convenience or socialization rather than medical need.
Excessive therapy sessions that do not match the patient’s condition or needs.
Therapy with no documented progress toward functional goals.
Duplicative therapy services when another provider (e.g., home health) is already billing for the same care.
💡 Example: If a patient with chronic low back pain receives therapy three times per week indefinitely without improvement, Medicare will likely deny further treatment.
Services Provided by Unqualified Personnel
Medicare only reimburses therapy services provided by licensed therapists or properly supervised assistants. Non-covered services include:
Therapy provided by aides, techs, or unlicensed staff.
Therapy performed by PTAs or OTAs without required supervision.
"Incident-to" services billed under a physician’s NPI without meeting direct supervision requirements.
💡 Example: If a therapy aide provides manual therapy techniques without a licensed PT supervising, the service is not covered.
Experimental, Investigational, or Alternative Therapies
Medicare does not cover treatments that are unproven, alternative, or investigational, including:
Alternative therapies such as acupuncture, massage therapy, Reiki, and reflexology.
Experimental therapy techniques without established clinical evidence.
Non-standard electrical stimulation or biofeedback devices that are not FDA-approved for Medicare reimbursement.
💡 Example: If a clinic offers craniosacral therapy or energy healing, Medicare will not reimburse these services.
Key Takeaways: What Medicare Does NOT Cover
✅ Therapy must require skilled intervention to be covered.
✅ All services must be under a physician-certified Plan of Care.
✅ Routine, repetitive exercises without therapist adjustment are not covered.
✅ Services performed by unqualified personnel are not reimbursable.
✅ Alternative or experimental therapies are not covered.
✅ Billing errors can result in denials—documentation must align with Medicare rules.