Ins. Benefits being denied

[aimee1]

What is the name of your state (only U.S. law)? CA

I do not understand how an insurance company can deny and prevent me from utilizing the benefits with in my policy. Listing my physically therapy as “not medically necessary” even though my physician has ordered such treatment, he has even written a letter to the ins. company. I understand that each policy has line items set up for denial. In my specific case I meet 2 but not the last one – “not improved in 2 weeks”. How is this possible???? Doesn’t everyone heal at a different rate and if its not improving doesn’t that further more show that I do need the theraphy…..

I am currently in the appeal process, naturally the ins. company is dragging it feet and in the meantime all of the work I have done in the last several months has gone down the drain…

I have never been in this situation and I have no clue where to go from here. What are my options?

[ecmst12]

Because they are abiding by the treatment guidelines outlined in your policy. PT exercises can easily be done at home and you should be doing them anyway. No improvement after 2 weeks can definitely be a sign that you've reached MMI (maximum medical improvement, as good as you're gonna get). You won't benefit more from PT in the office then from doing the exercises on your own. You haven't given many details but it sounds like you've been doing the therapy for a while. If it's not actively helping you every week (especially if you're going more then once a week) then most likely, it's done all the good it can do you. It means you either need to learn to live with your current level of functioning, or start exploring other avenues for treatment (surgery etc).