Insurers say annual visit limits help keep down costs, and therefore premiums, and are intended to prevent therapists from continuing treatment when patients are no longer improving. They say most injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority.<\/p>\n
Atul Patel, a physiatrist in Overland Park, Kansas, and the treasurer of the American Academy of Physical Medicine and Rehabilitation, said insurers\u2019 desire to prevent gratuitous therapy is understandable but has \u201cgone too far.\u201d<\/p>\n
\u201cMost patients get way less therapy than they would actually benefit from,\u201d he said.<\/p>\n
Hard caps on rehab endure in part because of an omission in the Affordable Care Act. While that law required insurers to cover rehab<\/a> and barred them from setting spending restrictions on a patient\u2019s medical care, it did not prohibit establishing a maximum number of therapy sessions a year.<\/p>\n More than 29,000 ACA health plans \u2014 nearly 4 in 5 \u2014 limit the annual number of physical therapy sessions, according to a KFF Health News analysis of plans sold last year to individuals and small businesses. Caps generally ranged from 20 to 60 visits; the most common was 20 a year.<\/p>\n Health plans provided by employers often have limits of 20 or 30 sessions as well, said Cori Uccello, senior health fellow at the American Academy of Actuaries.<\/p>\n \u201cIt\u2019s the gross reality in America right now,\u201d said Sam Porritt, chairman of the Falling Forward Foundation, a Kansas-based philanthropy that has paid for therapy<\/a> for about 200 patients who exhausted their insurance over the past decade. \u201cNo one knows about this except people in the industry. You find out about it when tragedy hits.\u201d<\/p>\n Even in plans with no caps, patients are not guaranteed unlimited treatment. Therapists say insurers repeatedly require prior authorization, demanding a new request every two or three visits. Insurers frequently deny additional sessions if they believe there hasn\u2019t been improvement.<\/p>\n \u201cWe\u2019re seeing a lot of arbitrary denials just to see if you\u2019ll appeal,\u201d said Gwen Simons, a lawyer in Scarborough, Maine, who represents therapy practices. \u201cThat\u2019s the point where the therapist throws up their hands.\u201d<\/p>\n \u2018Couldn\u2019t Pick Her Up\u2019<\/strong><\/p>\n Katie Kriegshauser, a 37-year-old psychologist from Kansas City, Missouri, developed pregnancy complications that shut down her liver, pancreas, and kidneys in November 2023. After giving birth to her daughter, she spent more than three months in a hospital, undergoing multiple surgeries and losing more than 40 pounds so quickly that doctors suspected her nerves became damaged from compression. Her neurologist told her he doubted she would ever walk again.<\/p>\n Kriegshauser\u2019s UnitedHealthcare insurance plan allowed 30 visits at Ability KC, a rehabilitation clinic in Kansas City. She burned through them in six weeks in 2024 because she needed both physical therapy, to regain her mobility, and occupational therapy, for daily tasks such as getting dressed.<\/p>\n \u201cAt that point I was starting to use the walker from being completely in the wheelchair,\u201d Kriegshauser recalled. She said she wasn\u2019t strong enough to change her daughter\u2019s diaper. \u201cI couldn\u2019t pick her up out of her crib or put her down to sleep,\u201d she said.<\/p>\n The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms. \u201cA huge amount of progress happened in that period after my insurance ran out,\u201d she said.<\/p>\n In an unsigned statement, UnitedHealthcare said it covered the services that were included in Kriegshauser\u2019s health plan. The company declined to permit an official to discuss its policies on the record because of security concerns.<\/p>\n A Shattered Teenager<\/strong><\/p>\n Patients who need therapy near the start of a health plan\u2019s year are more likely to run out of visits. Mari Villar was 15 and had been walking with high school friends to get a bite to eat in May 2023 when a car leaped over a curb<\/a> and smashed into her before the driver sped away.<\/p>\n The accident broke both her legs, lacerated her liver, damaged her colon, severed an artery in her right leg, and collapsed her lung. She has undergone 11 operations, including emergency exploratory surgery to stop internal bleeding, four angioplasties, and the installation of screws and plates to hold her leg bones together.<\/p>\n Villar spent nearly a month in Shirley Ryan AbilityLab\u2019s hospital in Chicago. She was discharged after her mother\u2019s insurer, Blue Cross and Blue Shield of Illinois, denied her physician\u2019s request for five more days, making her more reliant on outpatient therapy, according to records shared by her mother, Megan Bracamontes.<\/p>\n Villar began going to one of Shirley Ryan\u2019s outpatient clinics, but by the end of 2023, she had used up the 30 physical therapy and 30 occupational therapy visits the Blue Cross plan allowed. Because the plan ran from July to June, she had no sessions left for the first half of 2024.<\/p>\n \u201cI couldn’t do much,\u201d Villar said. \u201cI made lots of progress there, but I was still on crutches.\u201d<\/p>\n Dave Van de Walle, a Blue Cross spokesperson, said in an email that the insurer does not comment on individual cases. Razia Hashmi, vice president for clinical affairs at the Blue Cross Blue Shield Association, said in a written statement that patients who have run out of sessions should \u201cexplore alternative treatment plans\u201d including home exercises.<\/p>\n Villar received some extra sessions from the Falling Forward Foundation. While her plan year has reset, Villar is postponing most therapy sessions until after her next surgery so she will be less likely to run out again. Bracamontes said her daughter still can\u2019t feel or move her right foot and needs three more operations: one to relieve nerve pain, and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right.<\/p>\n \u201cTherapy caps are very unfair because everyone\u2019s situation is different,\u201d Villar said. \u201cI really depend on my sessions to get me to a new normalcy. And not having that and going through all these procedures is scary to think about.\u201d<\/p>\n \t\t\t\t\t \t\t\t\t\t Rationing Therapy<\/strong><\/p>\n Most people who use all their sessions either stop going or pay out-of-pocket for extra therapy.<\/p>\n Amy Paulo, a 34-year-old Massachusetts woman recovering from two operations on her left leg, maxed out the 40 visits covered by Blue Cross Blue Shield of Massachusetts in 2024, so she spent $1,445 out-of-pocket for 17 therapy sessions.<\/p>\n Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg \u2014 the difference a consequence of juvenile arthritis. Her recovery was prolonged, she said, because her femur didn\u2019t heal properly after one of the operations, in which surgeons cut out the middle of her femur and put a rod in its place.<\/p>\n \u201cI went ballistic on Blue Cross many, many times,\u201d said Paulo, who works with developmentally delayed children.\u201d<\/p>\n Amy McHugh, a Blue Cross spokesperson, declined to discuss Paulo\u2019s case. In an email, she said most employers who hire Blue Cross to administer their health benefits choose plans with \u201cour standard\u201d 60-visit limit, which she said is more generous than most insurers offer, but some employers \u201cchoose to allow for more or fewer visits per year.\u201d<\/p>\n Paulo said she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she\u2019ll need more help after an upcoming operation on her leg.<\/p>\n \u201cWe had to plan to save my visits for this surgery, as ridiculous as it sounds,\u201d she said.<\/p>\n Medicare Is More Generous<\/strong><\/p>\n People with commercial insurance plans face more hurdles than those on Medicare, which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document medical necessity. This year the limits are $2,410 for physical and speech therapy and $2,410 for occupational therapy.<\/p>\n Private Medicare Advantage plans don\u2019t have visit or dollar caps, but they often require prior authorization every few visits. The U.S. Senate Permanent Subcommittee on Investigations found last year that MA plans deny requests<\/a> for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other medical services.<\/p>\n Therapists say many commercial plans require prior authorization and mete out approvals parsimoniously. Insurers often make therapists submit detailed notes, sometimes for each session, documenting patients\u2019 treatment plans, goals, and test results showing how well they perform each exercise.<\/p>\n \u201cIt\u2019s a battle of getting visits,\u201d said Jackee Ndwaru, an occupational therapist in Jacksonville, Florida. \u201cIf you can\u2019t show progress they\u2019re not going to approve.\u201d<\/p>\n An Insurer Overruled<\/strong><\/p>\n Marjorie Haney\u2019s insurance plan covered 20 therapy sessions a year, but Anthem Blue Cross Blue Shield approved only a few visits at a time for the rotator cuff she tore in a bike accident in Maine. After 13 visits in 2021, Anthem refused to approve more, writing that her medical records \u201cdo not show you made progress with specific daily tasks,\u201d according to the denial letter.<\/p>\n Haney, a physical therapist herself, said the decision made no sense because at that stage of her recovery, the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion.<\/p>\n \u201cI went through those visits like they were water,\u201d Haney, now 57, said. \u201cMy range was getting better, but functionally I couldn\u2019t use my arm to lift things.\u201d<\/p>\n Haney appealed to Maine\u2019s insurance bureau for an independent review. In its report overturning Anthem\u2019s decision, the bureau\u2019s physician consultant, William Barreto, concluded that Haney had made \u201csubstantial improvement\u201d \u2014 she no longer needed a shoulder sling and was able to return to work with restrictions. Barreto also noted that nothing in Anthem\u2019s policy required progress with specific daily tasks, which was the basis for Anthem\u2019s refusal.<\/p>\n \u201cGiven the member\u2019s substantial restriction in active range of motion and inability to begin strengthening exercises, there is remaining deficit that requires the skills and training of a qualified physical therapist,\u201d the report said.<\/p>\n Anthem said it requires repeated assessments before authorizing additional visits \u201cto ensure the member is receiving the right care for the right period of time based on his or her care needs.\u201d In the statement provided by Stephanie DuBois, an Anthem spokesperson, the insurer said this process \u201calso helps prevent members from using up all their covered treatment benefits too quickly, especially if they don\u2019t end up needing the maximum number of therapy visits.\u201d<\/p>\n In 2023, Maine passed a law banning prior authorization<\/a> for the first 12 rehab visits, making it one of the few states to curb insurer limitations on physical therapy. The law doesn\u2019t protect residents with plans based in other states or plans from a Maine employer who self-insures.<\/p>\n Haney said after she won her appeal, she spaced out the sessions her plan permitted by going once weekly. \u201cI got another month,\u201d she said, \u201cand I stretched it out to six weeks.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n![](\"http:\/\/shapegreatness.org\/wp-content\/uploads\/2025\/03\/Rehab-denials-010-3840-scaled.jpg\")
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