Their physical therapy coverage ran out before they could walk again

By Jordan Rau KFF Robustness News Mari Villar was slammed by a car that jumped the curb current her legs and collapsing a lung Amy Paulo was in pain from a femur surgery that wasn t healing properly Katie Kriegshauser suffered organ failure during pregnancy weakening her so much that she couldn t lift her baby daughter All went to physical therapy but their healthcare insurers stopped paying before any could walk without assistance Paulo spent nearly out of her own pocket for more sessions Mari Villar at a therapy session with physical therapist C Ryan Coxe at Chicago s Shirley Ryan AbilityLab Jim Vondruska KFF Medical News TNS Millions of Americans rely on physical and occupational therapists to regain strength and motor skills after operations diseases and injuries But recoveries are routinely stymied by a widespread constraint in physical condition insurance policies rigid caps on therapy sessions Insurers frequently limit such sessions to as sparse as a year a KFF Fitness News examination finds even for people with severe damage such as spinal cord injuries and strokes who may need months of remedy multiple times a week Patients can face a bind Without therapy they can t return to work but without working they can t afford the therapy Paulo stated she pressed her insurer for more sessions to no avail I reported I m in pain I need the services Is there anything I can do she recalled They mentioned no they can t override the hard limit for the plan Mari Villar still can t manipulate her right foot nearly two years after a hit-and-run driver smashed into her Jim Vondruska KFF Soundness News TNS A typical physical therapy session for a privately insured subject to improve daily functioning costs on average according to the Robustness Care Cost Institute Preponderance run from a half hour to an hour Insurers say annual visit limits help keep down costs and therefore premiums and are intended to prevent therapists from continuing restoration when patients are no longer improving They say the greater part injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority Atul Patel a physiatrist in Overland Park Kansas and the treasurer of the American Academy of Physical Medicine and Rehabilitation revealed insurers desire to prevent gratuitous therapy is understandable but has gone too far Largest part patients get way less therapy than they would certainly benefit from he announced Mari Villar has had operations to repair the damage caused when a car crashed into her on a Chicago sidewalk broke both her legs and damaged her liver colon and one of her lungs Here she displays one of her surgical scars Jim Vondruska KFF Medical News TNS Hard caps on rehab endure in part because of an omission in the Affordable Care Act While that law required insurers to cover rehab and barred them from setting spending restrictions on a victim s anatomical care it did not prohibit establishing a maximum number of therapy sessions a year More than ACA strength plans nearly in limit the annual number of physical therapy sessions according to a KFF Strength News analysis of plans sold last year to individuals and small businesses Caps generally ranged from to visits the majority common was a year Vitality plans provided by employers often have limits of or sessions as well revealed Cori Uccello senior wellness fellow at the American Academy of Actuaries It s the gross reality in America right now stated Sam Porritt chairman of the Falling Forward Foundation a Kansas-based philanthropy that has paid for therapy for about patients who exhausted their insurance over the past decade No one knows about this except people in the industry You find out about it when tragedy hits Even in plans with no caps patients are not guaranteed unlimited restoration Therapists say insurers repeatedly require prior authorization demanding a new request every two or three visits Insurers frequently deny additional sessions if they believe there hasn t been improvement We re seeing a lot of arbitrary denials just to see if you ll appeal stated Gwen Simons a lawyer in Scarborough Maine who represents therapy practices That s the point where the therapist throws up their hands Couldn t pick her up Katie Kriegshauser a -year-old psychologist from Kansas City Missouri developed pregnancy complications that shut down her liver pancreas and kidneys in November After giving birth to her daughter she spent more than three months in a hospital undergoing multiple surgeries and losing more than pounds so promptly that doctors suspected her nerves became damaged from compression Her neurologist advised her he doubted she would ever walk again Kriegshauser s UnitedHealthcare insurance plan allowed visits at Ability KC a rehabilitation clinic in Kansas City She burned through them in six weeks in because she needed both physical therapy to regain her mobility and occupational therapy for daily tasks such as getting dressed At that point I was starting to use the walker from being wholly in the wheelchair Kriegshauser recalled She reported she wasn t strong enough to change her daughter s diaper I couldn t pick her up out of her crib or put her down to sleep she announced The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms A huge amount of progress happened in that period after my insurance ran out she declared In an unsigned comment UnitedHealthcare announced it covered the services that were included in Kriegshauser s wellbeing plan The company declined to permit an official to discuss its policies on the record because of shield concerns A shattered teenager Patients who need therapy near the start of a fitness plan s year are more likely to run out of visits Mari Villar was and had been walking with high school friends to get a bite to eat in May when a car leaped over a curb and smashed into her before the driver sped away The accident broke both her legs lacerated her liver damaged her colon severed an artery in her right leg and collapsed her lung She has undergone operations including crisis exploratory surgery to stop internal bleeding four angioplasties and the installation of screws and plates to hold her leg bones together Mari Villar at a therapy session with physical therapist C Ryan Coxe at Chicago s Shirley Ryan AbilityLab Jim Vondruska KFF Physical condition News TNS Villar spent nearly a month in Shirley Ryan AbilityLab s hospital in Chicago She was discharged after her mother s insurer Blue Cross and Blue Shield of Illinois denied her physician s request for five more days making her more reliant on outpatient therapy according to records shared by her mother Megan Bracamontes Villar began going to one of Shirley Ryan s outpatient clinics but by the end of she had used up the physical therapy and occupational therapy visits the Blue Cross plan allowed Because the plan ran from July to June she had no sessions left for the first half of I couldn t do much Villar stated I made lots of progress there but I was still on crutches Megan Bracamontes robustness insurance allows for only physical therapy sessions a year per person Her daughter Mari Villar left has needed extensive PT after she was hit by a car in Jim Vondruska KFF Medical News TNS Dave Van de Walle a Blue Cross spokesperson revealed in an email that the insurer does not comment on individual cases Razia Hashmi vice president for clinical affairs at the Blue Cross Blue Shield Association disclosed in a written comment that patients who have run out of sessions should explore alternative healing plans including home exercises Villar received various extra sessions from the Falling Forward Foundation While her plan year has reset Villar is postponing preponderance therapy sessions until after her next surgery so she will be less likely to run out again Bracamontes declared her daughter still can t feel or move her right foot and requirements three more operations one to relieve nerve pain and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right Therapy caps are very unfair because everyone s situation is different Villar declared I really depend on my sessions to get me to a new normalcy And not having that and going through all these procedures is scary to think about Rationing therapy Majority people who use all their sessions either stop going or pay out-of-pocket for extra therapy Amy Paulo a -year-old Massachusetts woman recovering from two operations on her left leg maxed out the visits covered by Blue Cross Blue Shield of Massachusetts in so she spent out-of-pocket for therapy sessions Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg the difference a consequence of juvenile arthritis Her recovery was prolonged she disclosed because her femur didn t heal properly after one of the operations in which surgeons cut out the middle of her femur and put a rod in its place I went ballistic on Blue Cross a large number of countless times noted Paulo who works with developmentally delayed children Related Articles Trump whacks tiny agency that works to make the nation s fitness care safer Tribes long shut out from their own vitality material fight for access and sovereignty Medicaid cuts could hurt older adults who rely on home care nursing homes Cluster of Massachusetts nurses reportedly diagnosed with brain tumors Shingles is awful but there may be another reason to get vaccinated It may fight dementia Amy McHugh a Blue Cross spokesperson declined to discuss Paulo s incident In an email she explained most of employers who hire Blue Cross to administer their soundness benefits choose plans with our standard -visit limit which she stated is more generous than preponderance insurers offer but certain employers choose to allow for more or fewer visits per year Paulo stated she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she ll need more help after an upcoming operation on her leg We had to plan to save my visits for this surgery as ridiculous as it sounds she reported Medicare is more generous People with commercial insurance plans face more hurdles than those on Medicare which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document healthcare necessity This year the limits are for physical and speech therapy and for occupational therapy Private Medicare Advantage plans don t have visit or dollar caps but they often require prior authorization every insufficient visits The U S Senate Permanent Subcommittee on Investigations determined last year that MA plans deny requests for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other biological services Therapists say several commercial plans require prior authorization and mete out approvals parsimoniously Insurers often make therapists submit detailed notes sometimes for each session documenting patients remedy plans goals and test results showing how well they perform each exercise It s a battle of getting visits stated Jackee Ndwaru an occupational therapist in Jacksonville Florida If you can t show progress they re not going to approve An insurer overruled Marjorie Haney s insurance plan covered therapy sessions a year but Anthem Blue Cross Blue Shield approved only a minimal visits at a time for the rotator cuff she tore in a bike accident in Maine After visits in Anthem refused to approve more writing that her diagnostic records do not show you made progress with specific daily tasks according to the denial letter Haney a physical therapist herself disclosed the decision made no sense because at that stage of her recovery the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion I went through those visits like they were water Haney now explained My range was getting better but functionally I couldn t use my arm to lift things Haney appealed to Maine s insurance bureau for an independent review In its assessment overturning Anthem s decision the bureau s physician consultant William Barreto concluded that Haney had made substantial improvement she no longer needed a shoulder sling and was able to return to work with restrictions Barreto also noted that nothing in Anthem s plan required progress with specific daily tasks which was the basis for Anthem s refusal Given the member s substantial restriction in working range of motion and inability to begin strengthening exercises there is remaining deficit that requires the skills and training of a qualified physical therapist the summary commented Anthem noted it requires repeated assessments before authorizing additional visits to ensure the member is receiving the right care for the right period of time based on his or her care demands In the declaration provided by Stephanie DuBois an Anthem spokesperson the insurer noted this process also helps prevent members from using up all their covered medication benefits too fast especially if they don t end up needing the maximum number of therapy visits In Maine passed a law banning prior authorization for the first rehab visits making it one of the limited states to curb insurer limitations on physical therapy The law doesn t protect residents with plans based in other states or plans from a Maine employer who self-insures Haney declared after she won her appeal she spaced out the sessions her plan permitted by going once weekly I got another month she disclosed and I stretched it out to six weeks KFF Vitality News Distributed by Tribune Content Agency LLC