The Complete CPT 97110 Appeal Guide: Winning Strategies for All Major Payers

Introduction

CPT 97110 is therapeutic exercise: exercises the therapist designs, teaches and progresses to treat a measured problem such as weakness, low endurance or limited motion. Physical therapists, occupational therapists and other qualified providers bill it, and payers often question it when the notes read like a routine exercise session rather than skilled care.

These denials cost healthcare providers significant lost revenue and administrative overhead. More importantly, they can delay or interrupt critical patient care when providers struggle with reimbursement uncertainty. This comprehensive guide provides battle-tested strategies for successfully appealing CPT 97110 denials across all major payers.

Whether you're dealing with medical necessity challenges, documentation deficiencies, or payer-specific policy interpretations, this guide will equip you with the specific knowledge needed to overturn denials and secure proper reimbursement for this essential therapeutic service.

Common Denial Reasons

Understanding why payers deny CPT 97110 claims is crucial for crafting effective appeals. Here are the seven most frequent denial reasons across all major payers:

1. Insufficient Medical Necessity Documentation

Payers frequently deny CPT 97110 when the submitted documentation fails to clearly establish why therapeutic exercise is medically necessary for the patient's specific condition. This includes vague treatment goals or lack of functional improvement measurements.

2. Missing or Inadequate Prior Authorization

Many payers require prior authorization for outpatient rehabilitation services, including CPT 97110. Claims submitted without proper authorization or exceeding authorized visit limits face automatic denial.

3. Lack of Physician Referral or Prescription

Most payers require a physician's referral, prescription, or plan of care before approving CPT 97110 services. Missing or expired referrals trigger immediate denials.

4. Exceeding Annual or Episode Visit Limits

Commercial plans often set visit limits in the member's benefits, and some require authorization for more visits. Medicare no longer has hard therapy caps; the Bipartisan Budget Act of 2018 repealed them. Medicare claims above the annual threshold need the KX modifier, which confirms the services are medically necessary, and claims above a higher amount can get targeted medical review.

5. Inadequate Progress Documentation

Payers deny claims when progress notes do not show the patient's status against the goals in the plan of care. Many commercial policies tie continued visits to functional improvement. Medicare does not: under the Jimmo v. Sebelius settlement (2013), coverage of skilled therapy does not depend on the patient improving, and maintenance therapy is covered when it needs a therapist's skills.

6. Duplicate or Overlapping Service Claims

When multiple therapy codes are billed together, payers may deny CPT 97110 if they determine the services overlap or represent duplicate treatment approaches.

7. Non-Covered Diagnosis Codes

Certain diagnosis codes may not meet a payer's criteria for CPT 97110, and some commercial plans exclude maintenance therapy. For Medicare, skilled maintenance therapy is covered when it needs a therapist's skills, so a maintenance denial on a Medicare claim can be appealed with documentation of that skilled need.

Payer-Specific Requirements

The notes below do not restate any payer's criteria. Policies change and differ by plan, so an appeal should quote the payer's current published policy for the member's plan, not a summary of it. Some plans hand utilization review for outpatient therapy to a separate company, so check the denial notice for who made the decision, and check the member's benefits for visit limits.

Aetna

Find Aetna's current clinical policy for physical or occupational therapy, and the member's plan documents. Quote the criterion the denial relies on and show where the notes meet it, especially the skilled work the therapist did in each session.

Anthem Elevance Health

Pull the current Anthem medical policy or clinical guideline that applies to the member's plan for this service. Match the record to each criterion it lists, and cite the document by title and date in the appeal.

Blue Cross Blue Shield

Blue Cross Blue Shield plans set their own medical policies, so requirements differ from plan to plan. For an out-of-area (BlueCard) member, only the member's home plan's medical policy applies, not your local plan's (BlueCard Program FAQ, Blue Cross and Blue Shield of Oklahoma). Enter the three-character prefix from the member ID card in your local Blue plan's out-of-area medical policy and prior authorization router to find the home plan's policy and prior authorization rules, and cite that policy in the appeal.

Cigna

Check Cigna's current coverage policy for this service and the member's plan documents. Quote the criterion the denial cites and show where the record meets it.

Humana

Humana announced in February 2023 that it would exit its employer group commercial medical business (Humana press release), so first confirm which Humana product the member has; Medicare Advantage and Medicaid plans follow different appeal rules. Medicare Advantage plans must follow Medicare national coverage determinations and the written coverage decisions (LCDs) of the Medicare contractor for the area (42 CFR 422.101(b)), so check the applicable NCD or LCD as well as Humana's own policy. For Medicare Advantage, the enrollee reconsideration window is 65 days from the notice, and contracted providers' payment disputes follow their contract.

Medicare Traditional

Medicare covers outpatient therapy furnished under a plan of care that a physician or nonphysician practitioner certifies, with recertification at least every 90 days. The initial signature is not needed when a written order or referral is on file and the therapist can show the plan was sent to the practitioner within 30 days of the initial evaluation (42 CFR 424.24(c)). The hard therapy caps were repealed by the Bipartisan Budget Act of 2018: claims above the annual threshold need the KX modifier confirming medical necessity, and claims above a higher amount can get targeted medical review. Coverage does not depend on the patient improving (Jimmo v. Sebelius settlement, 2013); maintenance therapy is covered when it needs the skills of a therapist. Check your MAC's LCD and billing article for outpatient therapy, if it has one, and cite the relevant section in the redetermination request.

Molina Healthcare

Molina offers Medicaid, Medicare and Marketplace plans (Molina Healthcare). Coverage criteria, prior authorization lists and appeal windows depend on the product and the state, so identify the member's plan first and use that plan's current policy and denial notice.

UnitedHealthcare

UnitedHealthcare keeps separate policy libraries for its commercial plans, its Medicare Advantage plans and its Community Plan (Medicaid) plans. Use the policy for the member's product, and quote the criterion the denial relies on.

Required Documentation Checklist

To maximize appeal success for CPT 97110 denials, ensure your documentation includes these essential elements:

Initial Evaluation Documentation:

• ☐ Complete medical history relevant to the condition
• ☐ Objective examination findings supporting functional deficits
• ☐ Baseline measurements using standardized assessment tools
• ☐ Clear identification of functional limitations
• ☐ Establishment of realistic, measurable treatment goals

Treatment Plan Documentation:

• ☐ Specific therapeutic exercises prescribed
• ☐ Rationale for exercise selection based on patient deficits
• ☐ Expected frequency and duration of treatment
• ☐ Anticipated functional outcomes
• ☐ Physician involvement in plan development

Progress Note Requirements:

• ☐ Date, duration, and specific CPT 97110 services provided
• ☐ Detailed description of therapeutic exercises performed
• ☐ Patient response to treatment
• ☐ Objective measurements of progress
• ☐ Any modifications made to treatment plan
• ☐ Assessment of continued medical necessity

Physician Documentation:

• ☐ Current plan of care or referral
• ☐ Medical necessity justification
• ☐ Oversight and involvement in treatment planning
• ☐ Approval for continued services when applicable

Outcome Measurements:

• ☐ Standardized assessment tools (when applicable)
• ☐ Functional improvement measures
• ☐ Pain scales or symptom tracking
• ☐ Return to activity or work status
• ☐ Patient-reported outcome measures

Sample Appeal Arguments

Argument 1: Skilled Therapeutic Intervention Necessity

"The denial of CPT 97110 services fails to recognize the skilled therapeutic intervention required for this patient's condition. The prescribed therapeutic exercises are not simple strengthening activities that could be performed independently, but rather specifically designed interventions requiring professional oversight for safety, progression, and effectiveness.

The patient's [specific condition] presents unique challenges including [specific impairments], which necessitate skilled assessment of exercise tolerance, real-time modification of exercise parameters, and professional monitoring for adverse responses. The enclosed documentation demonstrates that these CPT 97110 services involve complex clinical decision-making that cannot be replicated through a home exercise program or non-skilled intervention."

Argument 2: Documented Functional Improvement

"The submitted documentation clearly demonstrates significant functional improvement directly attributable to the CPT 97110 therapeutic exercise services. Objective measurements show [specific improvements with numbers/percentages] over the treatment period, with continued potential for additional gains.

These measurable improvements in [specific functional activities] directly impact the patient's ability to [specific daily activities or occupational tasks]. The consistent progress documented in the treatment notes refutes any suggestion that services were not medically necessary or that goals were not being achieved. The skilled therapeutic exercise interventions coded as CPT 97110 have proven essential to the patient's rehabilitation success."

Argument 3: Medical Necessity Based on Condition Complexity

"The complexity of the patient's condition [specific diagnosis/conditions] requires skilled therapeutic exercise intervention that meets all criteria for CPT 97110 coverage. The patient presents with [specific impairments/complications] that create safety concerns and require professional monitoring during exercise activities.

The medical literature supports the use of supervised therapeutic exercise for this condition, and the patient's response to treatment validates the appropriateness of the intervention. The enclosed physician documentation confirms the medical necessity of these services and supports the skilled nature of the therapeutic exercise program."

Argument 4: Prevention of Functional Decline

"The denial of CPT 97110 services overlooks the preventive value of continued therapeutic exercise in maintaining functional gains and preventing regression. The patient's condition [specific details] places them at high risk for functional decline without ongoing skilled intervention.

The documented evidence shows that discontinuation of supervised therapeutic exercise has previously resulted in [specific functional losses], demonstrating the ongoing medical necessity of CPT 97110 services. The skilled nature of these services lies in the continuous assessment, modification, and progression of exercises based on the patient's changing clinical status and functional capacity."

Filing Deadlines

Understanding appeal deadlines is crucial for maintaining your right to challenge CPT 97110 denials:

First Level Appeal Deadlines:

• Commercial and ERISA group plans: A member appeal, which the provider can often file as the member's authorized representative, can be filed for at least 180 days from the adverse benefit determination. Provider appeals under a participation contract follow the contract; those windows vary, so check the contract and the denial notice.
• Medicare Traditional: Redetermination within 120 days of receiving the initial determination (receipt is presumed 5 days after the notice date).
• Medicare Advantage: The enrollee, or a non-contracted provider with a waiver of liability, requests plan reconsideration within 65 days of the notice. Contracted providers' payment disputes follow their contract.
• Medicaid: Varies by state and managed care plan, so use the timeframe on the denial notice.

Second Level Appeal Deadlines:

• Medicare Traditional: reconsideration by a Qualified Independent Contractor within 180 days of receiving the redetermination, then an ALJ hearing, the Medicare Appeals Council and federal court, each within 60 days
• Medicare Advantage: an upheld plan reconsideration goes to the Independent Review Entity automatically
• Commercial plans: the plan documents or the provider contract set any second level, so check them

External Review Deadlines:

• Under the federal process, within 4 months of the final internal denial; state processes vary
• Standard decisions come within 45 days, expedited decisions within 72 hours

Key Timeline Considerations:

• Submit appeals as early as possible to preserve all options
• Track deadlines carefully for each payer and appeal level
• Consider requesting extensions if additional documentation is needed
• Maintain detailed records of all submission dates and communications

When to Request External Review

External review represents your final opportunity to overturn CPT 97110 denials when internal appeals have been exhausted. Consider requesting external review when:

Strong Clinical Cases:

• Clear medical necessity with comprehensive documentation
• Objective evidence of functional improvement
• Support from treating physician and medical literature
• Payer denial appears to contradict their own published policies

Policy Interpretation Disputes:

• Disagreement about what constitutes "skilled" therapeutic exercise
• Disputes over medical necessity criteria interpretation
• Challenges to coverage limitations not clearly stated in plan documents

Documentation Quality:

• Complete, detailed records supporting all aspects of care
• Objective measurements demonstrating improvement
• Clear correlation between CPT 97110 services and functional gains

External Review Success Factors:

• Engage independent medical experts when beneficial
• Present clear, organized documentation packages
• Focus on medical necessity and appropriateness of care
• Address payer's specific denial reasons systematically

The key to successful CPT 97110 appeals lies in thorough preparation, payer-specific knowledge, and persistent advocacy for appropriate patient care. By following these guidelines and adapting strategies to specific payer requirements, healthcare providers can significantly improve their appeal success rates and ensure patients receive the therapeutic exercise services they need for optimal recovery.

Each appeal is decided on its own claim and record, and an external review decision binds that claim only, so it does not set precedent for later claims. When the same denial keeps recurring, fix the documentation pattern behind it and raise the issue with the payer through your contract's dispute process.