Priority Health in the state of Michigan has announced they will provide coverage for patients to access physical therapy services without requiring a referral as allowed by the law for commercial products. This is due to a state law that took effect January 1, 2015 allowing anyone to seek physical therapy services without a physician referral for up to 21 days or 10 visits, whichever comes first. Medicaid patients still require a referral for physical therapy services as mandated by the state. To access this decision, click
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It is interesting to note that this policy is in direct conflict with the Jimmo VS Sebelius settlement with Medicare which mandates coverage of maintenance therapy for maintaining capability for chronic conditions. The policy states “The following services are excluded from coverage:
b. Therapy for the purpose of maintaining physical condition or maintenance therapy for a chronic condition is not a covered benefit.
c. Maintenance therapy for patients with spinal cord injuries.
d. Therapy which is long-term in patients with cerebral palsy.
e. Long-term treatment for patients with chronic (non-acute) musculoskeletal aches and pains. …”
The Jimmo Settlement states:
“Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” and “when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.” and “…a beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage.”
The Jimmo vs Sebelius settlement only applies to the Medicare program and not to private insurances or managed Medicaid programs.