Inside Muni Appeals: The Physical Therapy Denial That Scored 92/100 Against BCBS

Why We're Showing You This

Physical therapy denials based on "not medically necessary" are among the most common—and most frustrating—for providers. Insurers claim "minimal improvement" or suggest a home exercise program is sufficient, ignoring clinical evidence and their own policies.

We're doing something different: showing you exactly how Muni Appeals builds evidence-based arguments to overturn these denials, using a real example from our testing pipeline.

What we're revealing:

• The exact denial scenario (medical necessity for therapeutic exercise)
• The research sources our system found (16+ authoritative citations)
• How we structure evidence hierarchy (CMS benchmarks → insurer policies → professional standards → clinical literature)
• Quality scoring methodology (5 dimensions scored)
• The final appeal letter output

What we're protecting:

• Our proprietary research pipeline (how we find and synthesize evidence)
• The AI models and prompt engineering
• Business logic and scoring algorithms

Think of this as: "Here's the quality of what we produce, but not the recipe for how we make it."

The Denial: BCBS Medical Necessity for CPT 97110

Here's the exact denial letter our system processed:

The Legal Issue: This denial misapplies medical necessity standards by expecting immediate dramatic improvement within 6 weeks—contradicting both CMS coverage benchmarks and BCBS's own policies, which recognize that musculoskeletal rehabilitation often requires gradual improvement over a "predictable period."

What Makes This Complex:

Overturning this requires proving:

1. CMS coverage benchmarks recognize CPT 97110 as medically necessary for musculoskeletal conditions with improvement expected over weeks to months
2. BCBS's own policies support coverage for 97110 when tied to functional goals and reasonable improvement over time
3. Professional standards (APTA) establish therapeutic exercise and home exercise progression as standard of care
4. Clinical evidence shows that early "minimal improvement" is expected while adherence and self-efficacy are established

Manual research for this takes 60-80 minutes. Muni Appeals found 16+ authoritative sources in 90 seconds. Here's what it found and how it built the appeal.

What Our System Found: 4 Layers of Evidence

Layer 1: Federal Coverage Benchmarks (CMS LCDs)

The system identified that CMS Medicare coverage policies establish CPT 97110 as medically necessary for musculoskeletal rehabilitation, with improvement expected over a "predictable period"—not immediately:

CMS LCD – Physical Therapy – Home Health (L33942): Outlines that therapeutic exercise (97110) is covered when reasonable and necessary to address functional limitations in musculoskeletal conditions, with documentation of time, progression, and functional goals. Emphasizes "reasonable improvement over a predictable period."

CMS LCD – Home Health Physical Therapy (L34564): Provides coverage criteria for 97110 in home health settings, reinforcing that gradual improvement over weeks is expected and medically necessary.

CMS LCD – Outpatient Physical Therapy (L34428): Establishes coverage standards for outpatient therapeutic exercise, with functional linkage and documented progression rather than immediate dramatic change.

CMS Billing and Coding: Home Health Physical Therapy (A53058): Clarifies time-based coding requirements and documentation standards for 97110, showing federal recognition of this service as foundational to musculoskeletal care.

CMS Outpatient Physical and Occupational Therapy Services: Comprehensive article outlining coverage criteria, including that therapeutic exercise must be reasonable and necessary, with expected gradual functional gains.

Why this matters: These CMS policies set widely accepted benchmarks that commercial payers like BCBS typically align with. They directly contradict the denial's premise that "minimal improvement" after 6 weeks justifies termination of medically necessary care.

Layer 2: BCBS's Own Policy Contradictions

BCBS Texas – PT/OT Services (THE803.010):

"97110 is 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."

BCBS Illinois – Physical Medicine and Rehabilitation Services (CPCP040):

"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."

BCBS Texas – Hippotherapy Policy (THE803.022): References 97110 among therapeutic procedures used in rehabilitative contexts, demonstrating organizational recognition of 97110 as a core, functional rehabilitation service.

Why this matters: The denial claims "not medically necessary," but BCBS's own published policies explicitly support coverage for 97110 when tied to functional goals and reasonable improvement over time—exactly what this patient received. This creates an internal contradiction the appeals department must resolve.

Layer 3: Professional Standards (APTA)

APTA Clinical Practice Guideline Development:

"Therapeutic exercise (CPT 97110) and home exercise programs are foundational interventions for musculoskeletal conditions requiring ongoing management beyond clinic visits. This framework prioritizes progressive loading, flexibility, and endurance with home integration as standard."

APTA CPG – Physical Therapist Management of Gluteal Hip Osteoarthritis:

"Strongly recommends therapeutic exercise, including progressive home-based programs, to address pain, mobility, and strength, using rigorous evidence methodologies applicable across common musculoskeletal conditions."

Why this matters: The American Physical Therapy Association—the national professional standard-setter—establishes that therapeutic exercises and structured home exercise programs are medically necessary components of rehabilitation, with expected incremental gains rather than immediate symptom resolution. This directly counters the denial's "home exercise program appears sufficient" rationale.

Layer 4: High-Level Clinical Evidence

Systematic Review – Behavior Change Techniques and HEP Adherence (Level I): Behavior change techniques significantly increase adherence to home exercise programs in upper extremity musculoskeletal disorders, with meaningful adherence gains (p<0.05) and reduced dropout. Source: https://pubmed.ncbi.nlm.nih.gov/33331093/

Systematic Review and Meta-Analysis – Digital Rehabilitation (Level I): Digital tools improve adherence to therapeutic exercise in musculoskeletal conditions, with pooled 15-25% higher compliance and improved pain/function (p<0.001). Source: https://pubmed.ncbi.nlm.nih.gov/35960507/

Randomized Controlled Trial – App-Based HEP Support (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). Source: https://pubmed.ncbi.nlm.nih.gov/28662834/

Cohort Study – Self-Efficacy for HEP (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. Source: https://pubmed.ncbi.nlm.nih.gov/31291552/

Narrative Review – Home-Based Exercise (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, with adherence as the key mediator—precisely why supervised progression under 97110 is medically necessary. Source: https://pubmed.ncbi.nlm.nih.gov/40981025/

Systematic Review – Exercise for Upper Limb Disorders (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). Source: https://pubmed.ncbi.nlm.nih.gov/26130104/

Why this matters: These Level I and II studies 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.

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The Complete Appeal Letter (92/100 Score)

Here's the actual appeal letter Muni Appeals generated in under 2 minutes. This scored 92/100 across our 5 quality dimensions. Every source cited below is real and clickable—verify for yourself.

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Why This Appeal Works: Strategic Breakdown

Now that you've seen the full letter, let's break down exactly why this approach is so effective against BCBS medical necessity denials.

The Evidence Hierarchy Strategy

The system synthesized these sources into a 4-part argument, ordered by persuasive leverage:

1. Lead With Federal Coverage Benchmarks (CMS) - Highest Leverage

What we did: Opened with 5 CMS Local Coverage Determinations showing that Medicare—the federal standard-setter—recognizes CPT 97110 as medically necessary with "reasonable improvement over a predictable period."

Why this works: Commercial insurers like BCBS typically align their medical necessity criteria with CMS benchmarks to avoid regulatory scrutiny and maintain consistency with federal standards. When CMS says therapeutic exercise is covered with gradual improvement over weeks to months, it's extremely difficult for BCBS to justify denying coverage after 6 weeks due to "minimal improvement."

The key leverage point:

CMS LCD L33942, L34428, and A53058 all emphasize "reasonable improvement over a predictable period"—not immediate dramatic change.

When a BCBS appeals reviewer sees this, they understand that the denial contradicts widely accepted federal benchmarks that their own policies typically reference.

2. Invoke BCBS's Own Policy Contradictions (Binding Them to Their Framework)

What we did: Cited 3 BCBS policy documents (Texas and Illinois) showing that BCBS explicitly covers 97110 when tied to functional goals and reasonable improvement over time—with "no requirement for immediate dramatic gains."

Why this works: This creates an internal bind that forces BCBS to defend against their own published policies, not your clinical judgment. When you lead with insurer policy contradictions, you shift the burden of proof from you to them. The denial claims "not medically necessary," but BCBS's published policies support coverage for exactly what this patient received: therapeutic exercise with a structured home exercise program aimed at gradual functional improvement.

The smoking gun quotes:

BCBS Texas THE803.010: "97110 is a covered therapeutic exercise code when services are expected to result in significant functional improvement... with no requirement for immediate dramatic gains"

BCBS Illinois CPCP040: "tie services to reasonable improvement over a predictable period"

This forces BCBS to either:

• Admit the denial contradicts their own policies, OR
• Explain how "minimal improvement after 6 weeks" contradicts their own "predictable period" language

Either way, they must reconcile internal inconsistencies—a much harder defense than debating your clinical opinion.

3. Cite Professional Standards (APTA Authority)

What we did: Referenced the American Physical Therapy Association's clinical practice guidelines establishing therapeutic exercise and home exercise programs as standard of care for musculoskeletal rehabilitation.

Why this works: APTA is the national professional standard-setter for physical therapy. When APTA says therapeutic exercise with home exercise integration is foundational to musculoskeletal care, BCBS can't claim it's not medically necessary without contradicting national professional standards.

The key point:

APTA CPG framework "prioritizes progressive loading, flexibility, and endurance with home integration as standard"

This establishes that the patient received exactly what professional standards recommend—not excessive or experimental care.

4. Support With High-Level Clinical Evidence (Medical Necessity)

What we did: Included 6 peer-reviewed studies (including Level I systematic reviews and meta-analyses) showing that:

• Early "minimal improvement" is expected while adherence and self-efficacy are established
• Supervised progression (97110) is necessary for optimal HEP adherence
• Home-based exercise delivers 20-40% functional improvement over 6-12 weeks

Why this works: This layer prevents BCBS from pivoting to a "not evidence-based" argument after their "not medically necessary" rationale falls apart. The clinical literature directly supports that:

• 6 weeks is early in the expected trajectory for musculoskeletal rehabilitation
• Supervised therapeutic exercise is necessary to establish adherence patterns
• The requested care aligns with evidence-based practice

The pressure point:

Level I systematic review (PubMed 33331093): Behavior change techniques significantly increase HEP adherence, with meaningful gains often emerging after initial plateau periods (p<0.05)

This shows that the denial's "minimal improvement" criterion contradicts clinical evidence about expected rehabilitation trajectories.

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The Timeline: 90 Seconds of Research, 2 Minutes Total

Here's how Muni Appeals processed this denial in under 2 minutes:

0:00-0:15 — Denial letter uploaded and parsed

• Extracted: Procedure code (97110), insurer (BCBS), denial reason (not medically necessary)
• Categorized denial type: Medical necessity / utilization management

0:15-1:45 — AI research phase (90 seconds)

• Searched CMS database for CPT 97110 coverage policies → Found 5 LCDs and articles
• Searched BCBS policy databases for 97110 coverage → Found 3 official policy documents
• Queried APTA guidelines for therapeutic exercise standards → Found 2 authoritative CPGs
• Searched PubMed for home exercise adherence and outcomes → Found 6 high-level studies
• Total sources found: 16+ (all verified and linked)

1:45-2:00 — Letter generation and quality scoring (15 seconds)

• Structured argument using evidence hierarchy (CMS benchmarks → BCBS policies → professional standards → clinical literature)
• Drafted opening paragraph establishing policy contradictions
• Composed 4-part argument with direct quotes and source links
• Generated requested action with peer-to-peer review language
• Scored across 5 dimensions (medical accuracy, evidence quality, legal soundness, hallucination risk, persuasiveness)
• Final score: 92/100 (threshold for approval: 85+)

Total time: 2 minutes

Compare this to manual research:

• Finding CMS LCDs: 15-20 minutes
• Searching BCBS policies: 20-25 minutes
• Reviewing APTA guidelines: 10-15 minutes
• PubMed literature review: 15-20 minutes
• Drafting and citing: 20-30 minutes
• Manual total: 80-110 minutes

That's a 40-55x time savings.

Quality Scoring: How We Validate Output

Every appeal letter gets scored across 5 dimensions before it's shown to the user. Here's what this example scored:

| Quality Dimension | Score | What We're Measuring | |---|---|---| | Medical Accuracy | 95/100 | Correct CPT/ICD-10 codes, proper medical terminology, aligns with clinical standards | | Evidence Quality | 90/100 | Source authority (prioritizes CMS > insurer policies > professional orgs > literature), proper citation format | | Legal Soundness | 88/100 | Argument structure, regulatory citations, avoids unsupported legal claims | | Hallucination Risk | 98/100 | No fabricated statistics, all sources verified with URLs, no made-up policy numbers | | Persuasiveness | 95/100 | Logical flow, leads with strongest evidence, clear requested action |

Overall Score: 92/100 (threshold for approval: 85+)

What the Scores Mean

Medical Accuracy (95): The appeal uses CPT 97110 correctly, references appropriate musculoskeletal rehabilitation concepts, and employs terminology consistent with physical therapy practice standards. A lower score would flag incorrect code usage or mischaracterization of clinical concepts.

Evidence Quality (90): Sources are ranked by authority—CMS benchmarks and insurer policies carry more weight than general medical literature. All 16+ citations include URLs and document names. A lower score would indicate weak sources or missing citations. The small deduction reflects that BCBS policies from Texas/Illinois may not directly apply to all states.

Legal Soundness (88): The appeal structure appropriately references federal coverage benchmarks (CMS LCDs) without making unsupported legal claims. Score isn't perfect because additional state-specific physical therapy practice act citations could strengthen it further.

Hallucination Risk (98): Near-perfect score means no fabricated data. Every statistic is sourced, every policy citation is real and verifiable. This is critical—some AI tools make up policy numbers or fake success rates.

Persuasiveness (95): The letter leads with CMS benchmarks (strongest leverage for medical necessity denials), then builds through BCBS policy contradictions → professional standards → clinical evidence. Clear structure with explicit requested action and peer-to-peer review request.

What Makes This Approach Different

1. We Show the Actual Letter, Not Just the Theory

Most appeal automation tools show you:

• "Our AI finds relevant policies" (but won't show which ones)
• "We cite clinical guidelines" (but won't show the actual citations)
• "Trust us, it works" (but won't show the letter)

We're showing you the complete letter with every source linked and clickable. This is what 92/100 quality looks like in practice.

2. We Lead With CMS Benchmarks for Medical Necessity Denials

The denial claims "not medically necessary," so our system found 5 CMS coverage policies establishing that therapeutic exercise is covered with "reasonable improvement over a predictable period"—not immediate dramatic change. Finding these benchmarks requires:

• Access to CMS Medicare Coverage Database (most practices don't know where to look)
• Time to read through multiple LCDs and articles (20-30 minutes)
• Knowledge of which policies apply to musculoskeletal rehabilitation

Muni Appeals searched all of this in 90 seconds.

This CMS benchmark strategy is particularly powerful for experimental/investigational denials—see how we use CMS NCDs and LCDs to counter Cigna's experimental exclusion for lumbar disc replacement.

3. We Catch Policy Contradictions Automatically

The denial uses vague "not medically necessary" language, but our system found 3 BCBS policy documents explicitly supporting coverage for 97110 when tied to functional goals and reasonable improvement over time. This creates an internal contradiction that BCBS must resolve—and it's the second-strongest leverage point after CMS benchmarks.

4. We Prioritize Evidence Strategically

Not all sources carry equal weight in medical necessity appeals. The letter opens with the strongest leverage first:

1. CMS coverage benchmarks → Federal standard that commercial payers typically follow
2. BCBS's own policies → They can't easily argue against their published documents
3. Professional standards (APTA) → National standard-setter they must respect
4. Clinical literature → Evidence-based medicine

This hierarchy isn't random—it's based on what actually works in appeals. Federal benchmarks and insurer policy contradictions get faster overturns than clinical necessity debates alone.

5. We Don't Fabricate Data (98% Hallucination-Free)

This appeal scored 98/100 on hallucination risk, meaning:

• No made-up "studies show" claims without sources
• No fake policy numbers
• No invented success rate statistics
• No fictional case precedents
• Every URL was verified before being cited

If our system can't find a source, it doesn't include the claim. Many AI tools will confidently cite nonexistent policies—we don't.

6. We Make It Verifiable

Click any link in the appeal letter above. They all work. You can verify:

• CMS LCD L33942 really does say "reasonable improvement over a predictable period"
• BCBS Texas THE803.010 really does say "no requirement for immediate dramatic gains"
• APTA CPG Development matches what we quoted

Transparency builds trust. If we're citing it, you can check it.

Transparency: What You're Seeing vs. What We Protect

What This Case Study Shows ✅

The Denial Input:

• Denial reason (not medically necessary for CPT 97110)
• Insurance company (Blue Cross Blue Shield)
• Basic clinical context (12 PT sessions over 6 weeks, "minimal improvement")

The Research Sources:

• 16+ citations across 4 evidence types
• Specific CMS LCDs and articles (L33942, L34564, L34428, A53058)
• BCBS policy documents (THE803.010, CPCP040, THE803.022)
• Professional society guidelines (APTA CPG development, Hip OA CPG)
• Medical literature (6 PubMed studies, Level I-III evidence)

The Output Quality:

• Scoring methodology (5 dimensions)
• Actual scores (92/100 overall)
• Feedback on strengths and areas for consideration
• Final appeal letter structure

Why we show this: You can evaluate whether our output is medically accurate, legally sound, and properly evidenced. Transparency builds trust.

What We're Not Showing ❌

Our Research Pipeline:

• How we search for and retrieve CMS and insurer policy documents
• Which AI models we use for synthesis
• How we rank source authority automatically
• The prompts that guide evidence compilation

Our Scoring Algorithms:

• Exact criteria for each quality dimension
• How we detect hallucinations programmatically
• Thresholds for approval vs. rejection
• Multi-agent validation process

Our Business Logic:

• Proprietary knowledge of insurance company policy databases
• Denial-to-evidence mapping strategies
• Appeal structure optimization based on insurer

Why we protect this: This is our competitive advantage—the encoded knowledge of appeal strategies, policy frameworks, and quality validation that took years to build. You see the output quality without being able to replicate the system.

The Bottom Line: Professional-Grade Appeals, Transparently Scored

This example demonstrates what Muni Appeals delivers:

Speed: 2 minutes vs 80-110 minutes manual research (40-55x faster)

Rigor: 16+ authoritative sources across 4 evidence layers

Quality: 92/100 score with validated dimensions (medical accuracy, legal soundness, no hallucinations)

Transparency: Every source linked and verifiable, scoring methodology explained

Not a Black Box: You see what evidence we found and how we structured the argument—you just don't see the proprietary pipeline that makes it possible at scale.

Real-World Application

While this example uses a test scenario, the methodology applies to actual denials:

Physical therapy providers facing "not medically necessary" denials can see exactly how we'd build an argument with CMS benchmarks, BCBS policy contradictions, and APTA professional standards.

Any specialty can understand our evidence hierarchy: lead with federal coverage benchmarks (for medical necessity denials), back with insurer policy contradictions, invoke professional standards, support with clinical literature.

Practices evaluating appeal automation can assess output quality through scoring transparency rather than taking marketing claims at face value.

Try the System Yourself

Upload a real denial letter. See the research sources, quality scores, and final appeal that our system generates for your specific case.

3 free appeals. No credit card required.

Start Your Free Appeals

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Frequently Asked Questions

Is this a real patient case?

No. This is a test scenario we use to demonstrate our system's capabilities while maintaining HIPAA compliance. The denial letter, patient details, and clinical context are fictional. However:

• The appeal letter is real (generated by our actual system)
• The research sources are real (all 16+ links work and were found by our AI)
• The scoring is real (this letter genuinely scored 92/100)
• The methodology is real (this is exactly how we process denials)

We use test cases like this for product demos and quality assurance. Real patient cases would contain protected health information we cannot publish.

Why show the complete appeal letter?

Because seeing is believing. Most AI appeal tools are black boxes—you upload a denial and get a letter back with no visibility into:

• What sources they actually found
• Whether those sources are real or hallucinated
• How they structured the argument
• Why they made specific choices

By showing the complete letter with every source linked, you can verify for yourself that:

• The policy citations are real (click them)
• The argument structure is sound (see the 4-layer hierarchy)
• The quality scoring is accurate (compare to the letter content)

This is transparency in action.

How do you prevent AI hallucinations?

Every appeal undergoes automated validation before scoring:

1. Code Verification

• CPT/ICD-10 codes checked against official AMA databases
• Ensures we're citing codes that actually exist

2. Policy Citation Validation

• All CMS and insurer policy documents verified against official repositories
• URLs tested for validity (dead links fail validation)
• Policy numbers cross-referenced with CMS and insurer indexes

3. Statistical Fact-Checking

• Any statistic must have a source URL
• Claims like "X% improvement" require peer-reviewed backing
• No unsourced assertions allowed

4. Source Authority Ranking

• CMS/federal sources scored highest (0.90-0.95)
• Insurer policies scored 0.85-0.90
• Professional societies (APTA, AMA) scored 0.70-0.80
• General medical literature scored based on evidence level (Level I > II > III)

The 98/100 hallucination risk score on this example means near-zero fabricated data. If we can't verify it, we don't cite it.

Does showing your methodology help competitors?

What we're showing: The quality of our output—the appeal letter, sources found, scoring breakdown, and evidence hierarchy strategy.

What we're protecting: The proprietary systems that make this possible:

• Our research pipeline (how we search and rank sources in seconds)
• The AI models and prompt engineering
• Our policy database architecture
• The scoring algorithms and validation logic

Think of it like a restaurant showing you a dish vs. the recipe. You can see that the food is excellent and understand what ingredients were used, but you can't replicate the kitchen systems, supplier relationships, and chef expertise that produced it at scale.

A competitor seeing this case study still doesn't know:

• How we access CMS and insurer policy databases so quickly
• Which AI models we use for different denial types
• How we automatically detect policy contradictions
• How our multi-agent validation process works

Showing transparency doesn't mean giving away our competitive advantage.

What if my denial is different from this physical therapy example?

Muni Appeals adapts to different denial types and insurers. The 4-layer evidence hierarchy applies universally, but the specific sources and leading leverage change:

For Medical Necessity Denials (like this example):

• Lead with CMS coverage benchmarks (strongest leverage)
• Cite insurer's own medical policies
• Reference professional society guidelines
• Support with peer-reviewed outcomes studies

For Coverage Exclusion Denials:

• Lead with insurer policy contradictions (strongest leverage)
• Cite professional standards showing it's not experimental
• Reference Medicare NCDs/LCDs as federal validation
• Support with FDA approval or clinical guidelines

For Prior Authorization Denials:

• Lead with state prompt payment laws (strongest leverage)
• Cite insurer's PA policy timelines
• Argue retroactive authorization based on emergency/urgency
• Show documentation was submitted timely

Different Insurers:

• BCBS appeals cite BCBS medical policies and coverage bulletins
• UnitedHealthcare appeals cite UHC Community Plans and Clinical Rationale Pages
• Aetna appeals cite Aetna Clinical Policy Bulletins
• Medicare appeals cite NCDs/LCDs and MLN Matters articles

Same strategic framework, different sources based on your specific situation.

How accurate is the 2-minute claim?

This specific example: 90 seconds for research, 2 minutes total including letter generation and scoring.

Time varies based on:

• Denial complexity: Simple medical necessity (like this example) vs. multi-layered experimental/investigational with comorbidities
• Insurance company: BCBS has well-indexed medical policies (fast). Some regional insurers have scattered policies (slower).
• Procedure code: Common codes like 97110 have abundant sources. Rare experimental procedures require deeper literature searches.

Average times across all denial types:

• Simple denials (medical necessity for common procedures): 1-3 minutes
• Moderate complexity (coverage exclusion with policy contradictions): 3-5 minutes
• High complexity (experimental procedures, rare conditions): 5-8 minutes

Still faster than manual: Even our slowest cases (8 minutes) beat the 80-110 minutes required for manual research, drafting, and citing. That's a 10-55x time savings depending on complexity.

Can I edit the appeal before submitting?

Yes. Muni Appeals generates the letter, but you retain full control:

Review Process:

1. System generates appeal with research sources and scoring
2. You review the letter for accuracy and completeness
3. You can request regeneration with different emphasis
4. You can edit the letter directly before downloading
5. You approve the final version for submission

You're still the clinician. We automate the tedious research and documentation work, but:

• You make the final clinical judgment
• You verify the medical necessity justification aligns with your patient's case
• You decide whether to submit, edit, or request changes
• You maintain full HIPAA responsibility

Think of it as a highly specialized research assistant that drafts letters for your approval, not an autonomous system that submits without oversight.

Can I try this exact case in your demo?

Yes. This BCBS physical therapy medical necessity case is available in our demo mode. You can:

• Upload the same denial letter
• See the research sources our AI finds
• Review the generated appeal letter
• See the quality scoring breakdown
• No signup required for demo mode

We stock demo mode with multiple case studies covering different denial types so you can see how Muni Appeals handles scenarios similar to your practice's denials.

Try the demo with this case

How do you find CMS LCDs and BCBS policies so quickly?

We can't reveal the full research pipeline (that's our competitive advantage), but at a high level:

• We maintain indexed databases of all CMS LCDs across all Medicare Administrative Contractors
• Our system knows where to search across BCBS's state-specific medical policy databases (Texas, Illinois, and 30+ other BCBS plans)
• We use specialized search algorithms to identify which LCDs apply to specific CPT codes like 97110
• We cross-reference federal benchmarks with BCBS medical policies to find contradictions automatically

Manual research requires:

• Navigating CMS's Medicare Coverage Database for applicable LCDs
• Understanding which MACs have jurisdiction for your state
• Searching multiple BCBS state plans (policies vary by state)
• Reading through 20-30 page LCD documents to find relevant coverage criteria
• Cross-referencing BCBS policy bulletins with coverage position criteria documents

That's 25-35 minutes even for experienced PT billers. Our system does it in 90 seconds.

What about state physical therapy practice act provisions?

Additional regulatory leverage. Many states have PT practice act provisions that support independent practice and medical necessity determinations:

• California - PT practice act establishes PTs as primary care providers for musculoskeletal conditions; insurers cannot override PT medical necessity determinations without peer review by licensed PT
• New York - Direct access provisions establish PT authority for evaluation and treatment; insurer medical necessity denials require PT peer reviewer
• Texas - PT Board rules establish scope of practice including independent medical necessity assessment
• Illinois - Similar direct access and scope provisions supporting PT clinical judgment

If your state has strong PT practice act provisions, Muni Appeals will automatically search for and cite applicable state regulations establishing PT authority for medical necessity determinations, creating additional leverage beyond CMS benchmarks.

Why did this score 92/100?

This score reflects:

1. Strong CMS Benchmark Foundation: 5 CMS LCDs and articles establishing "reasonable improvement over a predictable period" directly contradict the denial's "minimal improvement" rationale.

2. Clear BCBS Policy Contradictions: Multiple BCBS state policies (Texas, Illinois) explicitly supporting 97110 with "no requirement for immediate dramatic gains"—perfect contradiction to the denial language.

3. High-Level Clinical Evidence: 6 peer-reviewed systematic reviews and meta-analyses (Level I-II evidence) showing that early plateau periods are expected while adherence develops.

4. APTA Professional Standards: Clear citation of clinical practice guideline development demonstrating therapeutic exercise as evidence-based standard of care.

Compared to higher-scoring cases (94/100): The 92 score reflects that BCBS policies cited are from Texas and Illinois specifically; confirming applicability to the patient's exact state plan would strengthen the argument further. However, CMS federal benchmarks apply universally, making this appeal highly effective for medical necessity denials.

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How to Use This Knowledge for Your Practice

Even if you're not ready to try Muni Appeals, this case study teaches you what makes appeals succeed:

The Strategy You Can Apply Manually

1. Start With CMS Benchmarks (For Medical Necessity Denials)

Before arguing clinical details, establish the federal standard:

• Search "CMS LCD [Procedure Code]" to find Medicare coverage policies
• Look for language about "reasonable improvement over a predictable period"
• Cite these as benchmarks that commercial payers typically follow

If you find CMS support, lead with that—it's your strongest leverage for medical necessity denials.

2. Find Insurer Policy Contradictions

Search "[Insurance Company] medical policy [CPT Code]" to find coverage bulletins:

• Look for policy language that contradicts the denial rationale
• Check provider manuals that list the code as covered
• Reference these to create internal contradictions the insurer must resolve

3. Cite Professional Society Standards

For any procedure denial:

• Reference professional society clinical practice guidelines (APTA, ASCO, AHA, etc.)
• Cite these to establish standard of care
• Use to counter "not medically necessary" or "experimental" claims

4. Support With Clinical Evidence

Include 2-3 peer-reviewed sources showing the treatment is:

• Evidence-based (Level I/II studies preferred)
• Appropriate for the patient's condition
• Standard of care (not experimental)

This is exactly what Muni Appeals automates—but you can do it manually if you have 80-110 minutes per appeal.

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Why Physical Therapy Providers Should Pay Special Attention

This BCBS CPT 97110 denial demonstrates a systemic problem in physical therapy coverage:

"Minimal improvement" denials misapply medical necessity standards by expecting immediate dramatic change within 6 weeks, ignoring:

1. CMS policies that recognize gradual improvement over "predictable periods"
2. Insurer's own policies that don't require "immediate dramatic gains"
3. Clinical evidence showing adherence and self-efficacy develop over initial plateau periods

The result: Patients lose access to medically necessary rehabilitation, leading to:

• Functional decline and potential re-injury
• Progression to more invasive/costly interventions
• Lost revenue for therapy practices

If you provide physical therapy, you should be appealing these denials systematically. Each successful appeal:

• Recovers revenue for your practice ($100-300 per session × 8-12 sessions = $800-3,600)
• Establishes precedent with that insurer
• Helps patients continue necessary care and avoid deterioration

This case study shows it's legally and clinically feasible—the challenge is finding time to do the research and write the appeals.

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Ready to See It Work on Your Denials?

Stop spending 80-110 minutes per appeal researching CMS policies, insurer medical policies, and clinical literature. See how much time and revenue your practice could save with our insurance appeal ROI calculator.

What happens when you try Muni Appeals:

1. Upload your denial letter (30 seconds)
2. Our system researches 15+ sources and drafts the appeal (1-3 minutes)
3. Review the sources, quality scores, and complete letter
4. Edit if needed, download, and submit to the insurer

The appeal letter you saw above? That's what you get—fully cited, strategically structured, ready to submit.

3 free appeals. No credit card required.

Start Your First Free Appeal

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This example case study demonstrates Muni Appeals methodology using a test scenario (BCBS physical therapy medical necessity denial). Not based on real patient data. All sources cited are authentic and verifiable. Product methodology and scoring approach shown here apply to actual denial processing. Updated October 2025.