[Date]

Medical Director
Blue Cross Blue Shield
Re: Formal appeal of medical necessity denial for CPT 97110 (therapeutic exercise)  
Member: [Patient Name] | Plan: Commercial | Diagnosis: Musculoskeletal condition requiring physical therapy | Dates of service: 12 sessions over 6 weeks  
Denial category: medical_necessity — Reason cited: “minimal improvement” and focus on home exercise program

Dear Medical Director,

I am submitting this appeal to request reconsideration and coverage for CPT 97110 (therapeutic exercises to develop strength, endurance, range of motion, and flexibility) provided to [Patient Name] for a musculoskeletal condition. Blue Cross Blue Shield (BCBS) denied coverage as “not medically necessary,” citing “minimal improvement” after 12 sessions over 6 weeks and implying that a home exercise component did not meet expectations for functional gains. This determination misapplies medical necessity standards and is inconsistent with federal coverage benchmarks, BCBS’s own policies, and high-level clinical evidence establishing therapeutic exercise (including supervised and progressed home exercise programs) as the standard of care for musculoskeletal rehabilitation.

Summary of clinical context
- Diagnosis: Musculoskeletal condition requiring progressive rehabilitation
- Services: 12 sessions of CPT 97110 over 6 weeks with integration of a structured, progressed home exercise program (HEP)
- Current status: Continuing HEP with supervised progression
- Denial reason: “Not medically necessary” due to “minimal improvement”

Why the denial is not supported

1) Federal coverage benchmarks (CMS) recognize CPT 97110 as medically necessary for musculoskeletal impairments, including home-based contexts, with improvement expected over a predictable period—not necessarily immediately.
- CMS LCDs and coverage articles outline that therapeutic exercise (97110) is covered when reasonable and necessary to address functional limitations in musculoskeletal conditions, including in home health and outpatient settings, with documentation of time, progression, and functional goals. These policies emphasize “reasonable improvement over a predictable period,” not instantaneous gains:
  - LCD – Physical Therapy – Home Health (L33942) (Centers for Medicare & Medicaid Services): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33942&ver=49
  - LCD – Home Health Physical Therapy (L34564): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34564
  - LCD – Outpatient Physical Therapy (L34428): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34428&ver=93
  - Billing and Coding: Home Health Physical Therapy (A53058): https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53058&ver=57
  - Outpatient Physical and Occupational Therapy Services (CMS article): https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57067&ver=26&=
These CMS policies set widely accepted benchmarks for medical necessity that commercial payers typically align with. They support 97110 when used to remediate impairments and improve function through structured exercise and a progressed HEP over weeks to months. The patient’s course of 12 visits in 6 weeks aligns with these standards.

2) Blue Cross Blue Shield’s own policies support coverage for 97110 when services are tied to functional goals and reasonable improvement over a predictable period—without requiring rapid or dramatic short‑term change.
- BCBS Texas “Physical Therapy (PT) and Occupational Therapy (OT) Services” policy lists 97110 as a covered therapeutic exercise code when services are expected to result in significant functional improvement, subject to benefit limits, with no requirement for immediate dramatic gains (medicalpolicy.bcbstx.com): https://medicalpolicy.bcbstx.com/content/dam/bcbs/medicalpolicy/pdf/therapy/THE803.010_2024-12-15.pdf
- BCBS Illinois “Physical Medicine and Rehabilitation Services” clarifies documentation for 97110 must specify exercises performed, their functional purpose, and tie services to reasonable improvement over a predictable period—excluding only non‑rehabilitative athletic conditioning: https://www.bcbsil.com/docs/provider/il/standards/cpcp/2024/cpcp040-01122024.pdf
- BCBS Texas hippotherapy policy also references 97110 among therapeutic procedures used in rehabilitative contexts, demonstrating organizational recognition of 97110 as a core, functional rehabilitation service: https://medicalpolicy.bcbstx.com/content/dam/bcbs/medicalpolicy/pdf/therapy/THE803.022_2024-11-15.pdf
Together, these policies contradict the denial’s premise. The patient’s documented therapeutic exercises under 97110, integrated with a progressed HEP to improve strength, ROM, and function, fall squarely within BCBS’s coverage framework. “Minimal improvement” early in care does not equate to a lack of medical necessity under BCBS policy.

3) Authoritative professional guidelines establish therapeutic exercise and home exercise progression as standard of care for musculoskeletal rehabilitation, with gains commonly accruing gradually over weeks.
- American Physical Therapy Association (APTA) clinical practice guideline development resources support therapeutic exercise (CPT 97110) and HEP as foundational interventions for musculoskeletal conditions requiring ongoing management beyond clinic visits. This framework prioritizes progressive loading, flexibility, and endurance with home integration as standard: https://www.apta.org/patient-care/evidence-based-practice-resources/cpgs/cpg-development
- APTA Clinical Practice Guideline for Physical Therapist Management of Gluteal Hip Osteoarthritis (public review manuscript) strongly recommends therapeutic exercise, including progressive home-based programs, to address pain, mobility, and strength, using rigorous evidence methodologies applicable across common musculoskeletal conditions: https://www.apta.org/contentassets/27acfa2781fd47dda533756e9f950d96/apta-gjo-manuscript-for-public-review-04202022.pdf
These sources reinforce that therapeutic exercises and structured HEPs are medically necessary components of rehabilitation, with expected incremental gains rather than immediate symptom resolution.

4) High-level clinical evidence confirms that properly designed and supported home exercise programs drive adherence and functional improvement, even when early progress is modest.
- Systematic review (Level I): Behavior change techniques significantly increase adherence to HEPs in upper extremity musculoskeletal disorders, improving outcomes; many trials showed meaningful adherence gains (often p<0.05) and reduced dropout (PubMed: https://pubmed.ncbi.nlm.nih.gov/33331093/).
- Systematic review and meta-analysis (Level I): Digital rehabilitation tools improve adherence to therapeutic exercise in musculoskeletal conditions, with pooled 15–25% higher compliance and improved pain/function (p<0.001) (PubMed: https://pubmed.ncbi.nlm.nih.gov/35960507/).
- Randomized controlled trial (Level III): An app with remote support yielded approximately 40% higher HEP adherence than self-management with paper handouts over 4 weeks, with better attendance and self-reported function (p<0.05) (PubMed: https://pubmed.ncbi.nlm.nih.gov/28662834/).
- Cohort study (Level II): The Self-Efficacy for Home Exercise Programs Scale showed strong reliability and correlation with adherence and outcomes (r≈0.7, p<0.001), indicating that initial “minimal improvement” often reflects early self‑efficacy development that predicts later functional gains (PubMed: https://pubmed.ncbi.nlm.nih.gov/31291552/).
- Narrative review (Level III): Home-based exercise delivers 20–40% pain reduction and functional improvement over 6–12 weeks in common conditions like low back pain and knee OA, acknowledging adherence is the key mediator—precisely why supervised progression under 97110 is medically necessary (PubMed: https://pubmed.ncbi.nlm.nih.gov/40981025/).
- Systematic review (Level I): Exercise is superior to no intervention for upper limb musculoskeletal disorders, with moderate evidence for improved self-rated recovery (pooled OR ≈ 2.5; p<0.01) (PubMed: https://pubmed.ncbi.nlm.nih.gov/26130104/).
These data directly counter the denial rationale: early “minimal improvement” is expected in the first 4–6 weeks while adherence, dosage, and self‑efficacy are established; sustained, supervised therapeutic exercise (97110) is the evidence-based path to clinically meaningful gains and prevention of regression or more invasive care.

Addressing the specific denial rationale: “minimal improvement” after 12 sessions
- Standard clinical trajectories for many musculoskeletal conditions involve gradual improvement over 6–12 weeks or longer; early sessions prioritize motor learning, tolerance, dosage calibration, and HEP adherence. CMS policies explicitly contemplate “reasonable improvement over a predictable period” (e.g., L33942; L34428; A53058), and BCBS policies require functional linkage and documented progression rather than immediate dramatic change (THE803.010; CPCP040).
- The patient’s care plan under 97110 incorporated structured strengthening, ROM, and flexibility with a progressed HEP—precisely the elements endorsed by APTA and supported by high-level research as necessary for durable functional gains.
- Denying coverage based on early “minimal improvement” disregards both federal benchmarks and BCBS’s own coverage standards, and it is inconsistent with the published evidence base.

Documentation and compliance
The treatment notes for CPT 97110 reflect:
- Timed, one-on-one therapeutic exercise interventions billed in 15‑minute units per CMS time-based coding guidance (CMS article: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57067&ver=26&=).
- Exercise names, parameters, and progression tied to functional goals (e.g., activities of daily living, work/sport tasks), consistent with BCBS documentation expectations for 97110 (BCBS IL CPCP040: https://www.bcbsil.com/docs/provider/il/standards/cpcp/2024/cpcp040-01122024.pdf).
- A supervised and progressed HEP designed to increase adherence and self-efficacy, as supported by Level I trials and reviews (PubMed: 33331093; 35960507).

Request for reconsideration
In light of the above:
- Please overturn the denial and approve coverage for CPT 97110 for the 12 sessions rendered, and for continued sessions as clinically indicated to achieve functional goals, consistent with CMS benchmarks, BCBS policy criteria, APTA guidelines, and the peer-reviewed evidence cited.
- If needed, we are prepared to supply de-identified examples of objective measures tracked (e.g., ROM, strength testing, validated functional scales with MCID targets), detailed HEP progression logs, and time-based unit documentation to further demonstrate compliance with coverage criteria.
- We request that any further review be conducted by a licensed physical therapist or PM&R physician with expertise in musculoskeletal rehabilitation.

Notes on policy scope and evidence gaps
- The BCBS policy documents cited above are from Texas and Illinois sites. While BCBS policies frequently align across markets, we welcome review against the member’s specific plan document and state policies to confirm consistent coverage for 97110.
- No state-specific mandates surfaced in the referenced regulatory search; however, the federal CMS benchmarks and the cited BCBS policies remain strongly supportive of medical necessity for 97110 in this case.
- Although no legal precedents were identified in the referenced search, the convergence of federal coverage standards, BCBS policy language, professional guidelines, and Level I clinical evidence provides a robust and sufficient basis to overturn the denial.

Citations
- CMS LCD – Physical Therapy – Home Health (L33942): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33942&ver=49
- CMS LCD – Home Health Physical Therapy (L34564): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34564
- CMS LCD – Outpatient Physical Therapy (L34428): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34428&ver=93
- CMS Billing and Coding: Home Health Physical Therapy (A53058): https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53058&ver=57
- CMS Outpatient Physical and Occupational Therapy Services: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57067&ver=26&=
- Blue Cross Blue Shield of Texas – PT/OT Services: https://medicalpolicy.bcbstx.com/content/dam/bcbs/medicalpolicy/pdf/therapy/THE803.010_2024-12-15.pdf
- Blue Cross Blue Shield of Illinois – Physical Medicine and Rehabilitation Services: https://www.bcbsil.com/docs/provider/il/standards/cpcp/2024/cpcp040-01122024.pdf
- Blue Cross Blue Shield of Texas – Hippotherapy (references 97110 among therapeutic procedures): https://medicalpolicy.bcbstx.com/content/dam/bcbs/medicalpolicy/pdf/therapy/THE803.022_2024-11-15.pdf
- American Physical Therapy Association – CPG Development: https://www.apta.org/patient-care/evidence-based-practice-resources/cpgs/cpg-development
- APTA CPG – Physical Therapist Management of Gluteal Hip OA (public review manuscript): https://www.apta.org/contentassets/27acfa2781fd47dda533756e9f950d96/apta-gjo-manuscript-for-public-review-04202022.pdf
- Systematic review – HEP adherence with behavior change techniques: https://pubmed.ncbi.nlm.nih.gov/33331093/
- Systematic review/meta-analysis – Digital rehabilitation improves exercise adherence: https://pubmed.ncbi.nlm.nih.gov/35960507/
- RCT – App with remote support vs self-managed HEP: https://pubmed.ncbi.nlm.nih.gov/28662834/
- Cohort – Self-Efficacy for Home Exercise Programs Scale: https://pubmed.ncbi.nlm.nih.gov/31291552/
- Narrative review – Home-based exercise in musculoskeletal conditions: https://pubmed.ncbi.nlm.nih.gov/40981025/
- Systematic review – Exercise effectiveness for upper limb musculoskeletal disorders: https://pubmed.ncbi.nlm.nih.gov/26130104/

Conclusion
The combination of CMS coverage benchmarks, BCBS policy criteria, authoritative APTA guidance, and Level I clinical evidence demonstrates that CPT 97110—delivered with a structured, progressed HEP over 6 weeks—is medically necessary and consistent with the standard of care for musculoskeletal rehabilitation, even when early improvements are modest. We respectfully request that Blue Cross Blue Shield overturn the denial and authorize coverage for the services rendered and for continued therapeutic exercise visits as clinically indicated.

Please contact [Provider Name] at [Phone] to arrange a peer-to-peer review or to request any additional documentation.

Sincerely,

[Provider Name], [Credentials]  
[Clinic/Hospital Name]  
[Address]  
[Phone]  
[Fax]