How to Appeal a UnitedHealthcare Physical Therapy Denial

You've just received another denial letter from UnitedHealthcare for physical therapy services, and the frustration is setting in. Your patient clearly needed those CPT 97110 therapeutic exercise sessions, yet UnitedHealthcare has denied payment citing vague reasons about medical necessity or visit limits. You're not alone—UnitedHealthcare denials for physical therapy, particularly CPT 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises), rank among the most frequent denials that rehabilitation practices face. The good news? These denials are often overturnable when you know exactly what documentation UnitedHealthcare requires and how to present your clinical case effectively.

Why UnitedHealthcare Denies Physical Therapy

Understanding UnitedHealthcare's specific denial patterns for CPT 97110 is crucial for crafting successful appeals. Their denial decisions typically stem from three primary areas where practices fall short of their documentation standards.

Visit Limit Exceeded Without Prior Authorization
UnitedHealthcare's medical policy establishes specific visit limits for physical therapy services, typically allowing 12-20 visits per episode of care depending on the diagnosis and treatment plan. However, many practices fail to recognize that UnitedHealthcare requires prior authorization before exceeding these thresholds. The insurer expects detailed functional improvement documentation and objective progress measurements before approving additional visits. When claims for CPT 97110 are submitted beyond the initial authorized visits without proper prior authorization, automatic denials occur. UnitedHealthcare's system flags these claims immediately, regardless of the patient's actual clinical progress.

Insufficient Medical Necessity Documentation
UnitedHealthcare applies stringent medical necessity criteria for therapeutic exercise services. Their clinical guidelines require specific documentation elements that many practices overlook. The insurer expects clear evidence that CPT 97110 services address functional limitations that significantly impact the patient's ability to perform activities of daily living or occupational tasks. Generic treatment notes stating "patient performed exercises" or "tolerated treatment well" trigger denials. UnitedHealthcare's medical policy requires quantifiable functional deficits, specific exercise parameters, and clear correlation between the therapeutic interventions and the patient's diagnosed condition.

Progress Not Adequately Documented
Perhaps the most challenging denial reason involves UnitedHealthcare's expectation for measurable functional progress throughout the treatment episode. Their reviewers look for objective improvements in range of motion, strength measurements, pain scales, and functional capacity. When progress notes fail to demonstrate advancing toward specific, measurable goals, UnitedHealthcare denies continued services under CPT 97110. The insurer's clinical guidelines specifically state that continued therapy must show "clinically meaningful improvement" in functional status, not merely maintenance of current levels or subjective patient reports of feeling better.

What You Need to Win This Appeal

Successfully overturning a UnitedHealthcare physical therapy denial requires assembling comprehensive clinical documentation that directly addresses their specific review criteria. Your appeal package must demonstrate both medical necessity and appropriate clinical progression through concrete evidence.

Complete Initial Evaluation and Plan of Care
Your appeal must include the comprehensive initial physical therapy evaluation that established baseline functional measurements. UnitedHealthcare requires objective documentation of range of motion limitations, strength deficits (measured via manual muscle testing or dynamometry), pain levels using standardized scales, and functional limitations that impact activities of daily living or work activities. The initial plan of care should specify measurable short-term and long-term goals with projected timeframes for achievement.

Objective Progress Documentation
Compile all progress notes that demonstrate quantifiable improvements in the patient's functional status. UnitedHealthcare's reviewers expect to see advancing measurements in areas such as range of motion degrees, strength grades, pain scale improvements, and functional capacity enhancements. Include any standardized outcome measures utilized, such as the Oswestry Disability Index for back pain or the DASH questionnaire for upper extremity conditions. These validated tools carry significant weight in UnitedHealthcare's review process.

Physician Orders and Supporting Medical Records
Include all physician referrals, prescription orders for physical therapy, and relevant medical records that support the need for therapeutic exercise interventions. UnitedHealthcare requires clear physician involvement in the treatment plan, including any modifications to the therapy prescription based on patient progress. If the denial involves exceeding visit limits, include physician documentation supporting the need for continued care beyond the initial authorization period.

Clinical Guidelines Correlation
Reference relevant clinical practice guidelines that support the use of therapeutic exercise for the patient's specific diagnosis. The American Physical Therapy Association's clinical practice guidelines, specialty society recommendations, and evidence-based treatment protocols help establish medical necessity. UnitedHealthcare's medical policies often align with recognized clinical guidelines, making this correlation powerful appeal evidence.

Step-by-Step: Appealing Your UnitedHealthcare Physical Therapy Denial

UnitedHealthcare maintains specific procedural requirements for physical therapy appeals that must be followed precisely to avoid additional delays or automatic rejections.

File Within Required Timeframes
UnitedHealthcare allows 365 days from the initial denial date to file your first-level appeal for CPT 97110 services. However, filing earlier improves your chances of success and faster resolution. Mark your calendar immediately upon receiving the denial notice, as missing this deadline results in forfeiture of appeal rights.

Submit to Correct Address and Include Required Information
Mail your appeal to UnitedHealthcare's designated appeals processing center, including the member's ID number, dates of service, claim numbers, and provider NPI. Include a cover letter clearly stating you are filing a "first-level appeal" for the denied CPT 97110 services. UnitedHealthcare processes appeals more efficiently when all required identification information appears prominently on the submission.

Structure Your Appeal Letter Strategically
Begin your appeal letter with a clear statement of the services being appealed and the specific denial reason you're addressing. Organize your clinical argument logically, starting with medical necessity justification, followed by progress documentation, and concluding with policy compliance evidence. Use bullet points and headers to make your appeal easy for reviewers to navigate quickly.

Request Peer-to-Peer Review When Appropriate
For complex cases or high-value denials, request a peer-to-peer review with UnitedHealthcare's medical director. This option allows the treating physical therapist to discuss the case directly with the reviewing physician, providing opportunity to clarify clinical reasoning and address specific concerns. Request this review in your initial appeal letter to expedite the process.

Sample Appeal Arguments for Physical Therapy Denials

Crafting compelling clinical arguments requires connecting your patient's specific clinical presentation to UnitedHealthcare's medical necessity criteria using language that resonates with their review process.

Functional Limitation Argument for Medical Necessity
"The patient presents with significant functional limitations impacting activities of daily living, as evidenced by inability to reach overhead (shoulder flexion limited to 90 degrees) preventing performance of essential self-care activities. CPT 97110 therapeutic exercise interventions specifically target these functional deficits through progressive range of motion and strengthening exercises designed to restore overhead reaching capacity. UnitedHealthcare's medical policy recognizes therapeutic exercise as medically necessary when addressing functional limitations that significantly impact daily activities, which is clearly demonstrated in this case."

Measurable Progress Documentation
"Objective measurements demonstrate clinically significant improvement throughout the treatment episode. Initial evaluation revealed 4/5 hip abductor strength with positive Trendelenberg gait pattern. Following CPT 97110 therapeutic exercise interventions, repeat testing shows 4+/5 strength with resolution of gait deviation, representing meaningful functional progress. Pain levels decreased from 7/10 to 3/10 on numerical rating scale, with corresponding improvement in walking tolerance from 2 blocks to 6 blocks without assistive device. This documented progress meets UnitedHealthcare's criteria for continued medically necessary care."

Clinical Guidelines Compliance
"Treatment approach aligns with established clinical practice guidelines for this diagnosis. The American Physical Therapy Association's clinical practice guidelines specifically recommend therapeutic exercise interventions (CPT 97110) as first-line treatment for this condition. The prescribed exercise program targets identified impairments through evidence-based interventions supported by multiple randomized controlled trials. UnitedHealthcare's medical policy typically aligns with recognized clinical guidelines, supporting coverage for these medically necessary services."

Visit Limit Justification
"While the patient has received the initially authorized number of visits, continued CPT 97110 services remain medically necessary due to ongoing functional deficits that impact work-related activities. The patient's job requires lifting 50 pounds regularly, yet current functional capacity testing reveals only 30-pound lifting tolerance. Continued therapeutic exercise is required to achieve full functional restoration and prevent re-injury. UnitedHealthcare's policy allows for visit limit extensions when functional goals remain unmet despite documented progress toward achievement."

Key Takeaways

• Address UnitedHealthcare's specific denial reason directly with objective clinical documentation that demonstrates medical necessity and functional improvement rather than generic treatment summaries.

• File your appeal within 365 days and include all required identification information, but don't wait—earlier submissions typically receive faster processing and resolution.

• Document measurable progress using standardized outcome tools and objective measurements that clearly show functional advancement throughout the CPT 97110 treatment episode.

• Connect your clinical evidence to established guidelines and UnitedHealthcare's medical policy criteria using specific language that mirrors their review standards for therapeutic exercise services.

Tools like AI-powered appeal generators can draft your Physical Therapy appeal letter in under 2 minutes, matching your clinical documentation to UnitedHealthcare's specific criteria.