Turn Every Denial Into Cash

Re: Formal Appeal of Medical Necessity Denial for CPT 97110 (Therapeutic Exercise)
Patient: Sarah Johnson, DOB: 03/14/1985
Member ID: XYH789456123
Claim/Reference No.: PA2024-789456

To the Medical Review Department:

I am writing on behalf of the above-named patient to formally appeal Blue Cross Blue Shield's denial of coverage for CPT 97110 (therapeutic exercises) on the stated basis of "medical necessity." We respectfully request reconsideration and full payment for the disputed services.

Summary of the medical record and treatment rationale
- The patient was referred for outpatient rehabilitative therapy with objectively documented functional limitations and impairments appropriate for therapeutic exercise, including measurable deficits in strength, range of motion, endurance, and activity tolerance that interfered with activities of daily living and mobility.
- A physician-signed plan of care established individualized, measurable, and time-bound functional goals. Therapeutic exercises were prescribed and progressed to restore strength, flexibility, range of motion, and endurance supporting functional task performance.
- Each billed unit of 97110 reflects one-to-one, skilled therapist interaction, with treatment minutes documented in compliance with time-based coding standards.

Medical necessity and coverage criteria

1) CMS coverage criteria for skilled therapy services
Medicare policy recognizes therapeutic exercise as a covered skilled service when it is reasonable and necessary to improve or restore function and requires the skills of a qualified therapist to safely and effectively deliver or progress the intervention. The Medicare Benefit Policy Manual identifies that skilled therapy is covered when the patient's condition requires therapist-level judgment, ongoing assessment, and modification of the plan of care to attain established, measurable goals.

2) Alignment with Blue Cross Blue Shield medical necessity principles
BCBS medical policies for outpatient physical/occupational therapy typically require: documented functional impairment; an individualized, goal-directed plan of care; services that are skilled (not maintenance that can be performed independently); and ongoing progress or skilled need for safe program establishment/progression.

Evidence base supporting supervised therapeutic exercise (97110)
The medical literature and clinical guidelines support supervised, progressive therapeutic exercise to reduce pain and improve function across common musculoskeletal and general rehabilitation conditions:

- Systematic review—low back pain: Exercise therapy provides clinically meaningful improvements in pain and function compared with minimal care/no treatment
- Osteoarthritis/knee function: High-quality evidence supports therapeutic exercise to improve pain and functional status
- Professional guidance: The APTA Guide to Physical Therapist Practice recognizes therapeutic exercise as a core skilled intervention

Requested action
Given the documented functional impairments, skilled need, evidence-based nature of 97110, and adherence to coverage criteria, we respectfully request that Blue Cross Blue Shield:
- Reverse the denial based on medical necessity; and
- Reprocess and pay the claim for CPT 97110 for the dates of service listed.

References
1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 220
2. Hayden JA, Ellis J, Ogilvie R, et al. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021
3. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2015

[Full medical documentation and citations attached]