care & love
At the heart of almost every insurance-related rehab struggle is the term "medically necessary." Insurance companies swear they cover "medically necessary" care, but what does that really mean? For patients, it often feels like a subjective judgment call that changes based on who's reviewing the claim that day.
Take robotic gait training, a cutting-edge therapy that uses technology to help patients with mobility issues (like those recovering from spinal cord injuries or strokes) relearn how to walk. Studies show it can improve balance, reduce fall risk, and boost independence—but many insurers limit coverage to "severe" cases, leaving others out in the cold. A physical therapist in Ohio shared that she's had to fight for coverage for a patient with multiple sclerosis who could barely stand unassisted, only to be told, "This isn't severe enough." How severe is severe enough? When you're the one struggling to take a single step, the answer feels obvious—but to an insurance adjuster, it's just a checkbox.
Even worse, "medical necessity" can exclude entire categories of rehab tools. Lower limb rehabilitation exoskeletons, for example, are revolutionary for patients with paraplegia or severe weakness—they can help people stand, walk, and rebuild muscle. But insurers often label them "experimental" or "not proven," despite FDA approval and decades of research. For patients, this isn't just about technology—it's about dignity. Being told you can't access a device that could let you hug your kid standing up? That stings more than the physical pain.
Imagine finally getting a referral to a top rehab clinic, only to be told you can't start therapy until your insurance approves it. That's prior authorization—a process where insurers require doctors to "prove" you need care before they agree to cover it. In theory, it's supposed to prevent unnecessary spending. In practice, it's a months-long waiting game that can derail recovery.
Physical therapists report spending 10-15 hours a week just on prior authorization paperwork—time they could be spending with patients. For patients, delays can mean muscles atrophy, pain worsens, or progress stalls. A study by the American Physical Therapy Association found that 70% of therapists have seen patients' conditions decline while waiting for prior auth approval. For someone recovering from a stroke, every day without therapy matters—brain plasticity fades over time, making it harder to regain function.
And if the authorization is denied? You start over. File an appeal, gather more medical records, wait another 2-4 weeks. By then, many patients give up. "I fought for three months to get approval for aquatic therapy for my chronic back pain," said Linda, a 52-year-old teacher. "By the time they said yes, my pain was so bad I could barely sit through a class, let alone drive to the clinic. I just… stopped trying."
Even when rehab is "covered," patients are often hit with steep out-of-pocket costs. Deductibles, coinsurance, and copays add up fast—especially for long-term rehab. A 2023 survey found that the average patient pays $1,200 a year out of pocket for rehab services, even with insurance. For low-income families or those with chronic conditions, that's a crisis.
Take electric nursing beds, a critical tool for home rehab. For patients recovering from hip surgery or living with mobility issues, an electric bed can adjust positions to reduce pain, prevent bedsores, and make transfers safer for caregivers. But insurers often classify them as "durable medical equipment" (DME), which comes with high cost-sharing. A basic electric nursing bed can cost $2,000-$5,000, and insurers might cover only 50% after you meet a $1,000 deductible. That's $1,500-$3,000 out of pocket—money many families don't have.
And it's not just big-ticket items. Weekly physical therapy copays of $30 add up to $1,560 a year. For someone on disability or a fixed income, that's choosing between therapy and groceries. No one should have to decide between getting better and feeding their family—but it happens every day.
Rehab doesn't stop when you leave the clinic. Most recovery happens at home—with tools like exercise bands, gait trainers, or electric nursing beds. But insurers rarely cover these "home use" items, even if they're essential for progress.
Consider the electric homecare nursing bed. For patients with limited mobility, it's not just a bed—it's a safety device. It lowers to the floor to prevent falls, raises to help caregivers assist with transfers, and tilts to reduce swelling. But insurers often argue that "a regular bed works fine" or that home care should be handled by family. "My dad has ALS, and he can't move on his own," said Mike, 39. "We needed a bed that tilts so he doesn't choke when eating. Insurance said, 'Hire a home health aide to adjust him manually.' But aides cost $25 an hour, 24/7—that's $18,000 a month! The bed was cheaper, but we still had to pay for it ourselves."
Even basic tools like reachers, shower chairs, or therapy balls are often excluded. Patients end up buying them at pharmacies or online, spending $50-$200 on items that could be covered. For lower-income patients, this is a choice between rehab and other essentials. "I needed a cane with a seat for my knee pain, but insurance wouldn't cover it," said Raj, 65. "I bought a cheap one at a discount store, but it broke after a month. Now I'm scared to walk outside alone."
Insurance plans are designed for short-term injuries—like a broken leg that heals in 6-8 weeks. But what about chronic conditions? Patients with multiple sclerosis, cerebral palsy, or spinal cord injuries need lifelong rehab to maintain function. Yet most insurance plans cap rehab visits—often at 20-30 sessions a year. Once you hit the cap, you're on your own.
"I have cerebral palsy, and I need weekly physical therapy to keep my muscles from tightening up," said Zoe, 27. "My insurance covers 26 sessions a year. That's two months of therapy. The rest of the year, I pay $80 a session out of pocket. I work part-time because of my disability, so that's $400 a month—half my income. Some months, I skip sessions to pay rent. Then my legs hurt more, and I can't walk as well. It's a cycle."
Long-term care insurance can help, but it's expensive—$2,000-$5,000 a year for a policy. Most families can't afford it, leaving patients to rely on Medicare or Medicaid, which have their own strict limits. For example, Medicare covers up to 100 days of skilled nursing care after a hospital stay—but only if you're "making progress." If you plateau? They cut you off.
To see just how inconsistent coverage can be, we compared three major insurance plans on key rehab services. The results? A patchwork of limitations that leave patients guessing.
| Service/Tool | Plan A (Large Employer) | Plan B (ACA Marketplace) | Plan C (Medicaid) |
|---|---|---|---|
| Robotic Gait Training | Covered: 12 sessions/year; $50 copay/session | Not covered (labeled "experimental") | Covered: 8 sessions/year; prior auth required |
| Lower Limb Rehabilitation Exoskeleton | Not covered (except for "severe paraplegia") | Not covered | Covered only in inpatient settings |
| Electric Nursing Bed (Home Use) | 50% coverage after $1,000 deductible | Not covered | Covered if "medically necessary"; 3-month wait |
| Physical Therapy Visits | 30 visits/year; $30 copay | 20 visits/year; 20% coinsurance | Unlimited (but prior auth for >10 visits) |
| Out-of-Pocket Max (Annual) | $8,500 | $9,100 | $2,000 (varies by state) |
As the table shows, even "good" plans have strict limits. For someone needing long-term rehab or specialized tools, there's no escaping high costs or denials. It's no wonder 40% of patients skip recommended rehab because of cost, according to a 2022 survey by the National Rehab Association.