MedExPRO case study shows exactly how to get paid for MET services

**Insurance reimbursement can feel like a mystery for many Medical Exercise Professionals—**you're delivering results, but not getting paid. That was reality for Kevin James, MES—until he discovered the six essential criteria for claim approval. His journey from frustration to reimbursement success offers a clear roadmap for every MedExPRO ready to get paid for the work they’re already doing. Read on and learn how Kevin learned how to manage his MET insurance claim. 

Client Background

Client Name: Joan D.
Age: 62
Primary Diagnosis: Post-Total Knee Replacement (Right)
Comorbidities: Type 2 Diabetes, Mild Obesity
Insurance: Blue Cross Blue Shield PPO

Joan had completed physical therapy after her total knee replacement surgery but continued to struggle with activities of daily living (ADLs)—specifically stairs, walking without fatigue, and standing for prolonged periods.

MedExPRO: Kevin James, MES

Kevin is a certified METI-Medical Exercise Specialist with 4 years of experience in post-rehab training. After attending the Cracking the Code workshop, he began implementing the 6-Point Reimbursement Criteria outlined by METI.

Applying the Six Criteria

1. Medical Referral Secured

Kevin reached out to Joan’s orthopedic surgeon, who agreed to provide a written referral for ongoing exercise services due to Joan’s persistent functional deficits. The referral included diagnosis codes and a note that she had completed her formal physical therapy.

✅ Criteria Met

2. Completion of Professional Rehab

Joan had completed 12 sessions of outpatient physical therapy. Her discharge notes indicated she had reached maximum medical improvement but still had functional deficits.

Kevin requested and attached the PT discharge summary to her MET documentation.

✅ Criteria Met

3. Qualifying Medical History

Joan had undergone a major orthopedic surgery (TKR) and was managing chronic diabetes—both conditions met the threshold for “major trauma or chronic condition.”

✅ Criteria Met

4. Residual Functional Deficits

Kevin performed an initial MET evaluation and documented Joan’s deficits:

• Difficulty descending stairs 

• Limited single-leg stance on surgical side (5 seconds max)

• Moderate fatigue after 5 minutes of treadmill walking

These were clearly listed in her assessment with baseline measurements.

✅ Criteria Met

5. Private Insurance Coverage

Joan’s plan was through a private insurer, not Medicare or Medicaid, and her PPO plan allowed for reimbursement of out-of-network post-rehab exercise services with proper documentation.

✅ Criteria Met

6. Goals + Structured Exercise Plan

Kevin established measurable short- and long-term goals, including:

• Increase stair navigation to 15 consecutive stairs without handrail

• Improve treadmill tolerance to 15 minutes at 3.0 mph

• Maintain postural alignment during walking for 10 minutes

His plan outlined progressions and checkpoints every 4 weeks.

✅ Criteria Met

Submission & Reimbursement Process

Kevin submitted the claim using:

• CPT Code 97110 (Therapeutic Exercise – 2 units)

• ICD-10 Codes: Z96.651 (Presence of Right Knee Implant), E11.9 (Type 2 Diabetes without Complication)

• Documentation included: Referral, PT discharge, MET evaluation, and progress plan

He used the MES Revenue Services system to submit through a clearinghouse.

Outcome

• Claim processed and reimbursed at 80% of the billed rate

• Joan completed a 12-week program with full resolution of deficits

• Kevin received 3 additional client referrals from the same orthopedic group after providing outcomes

Key Lessons

• Documentation drives reimbursement—especially functional deficits and goals

• Direct communication with physicians builds trust and ongoing referrals

• Understanding the exact insurance requirements prevents denials and audits

Final Note from Kevin

“Before I learned the 6-point criteria, I thought insurance reimbursement was out of reach. Now it’s part of my business model—and I’m not just making more money, I’m helping more people complete their recovery the right way.”

Now, Kevin’s getting reimbursed and generating referrals from local physicians. This Friday, April 25 at Noon ET, we’ll walk you through the 6 MET Insurance Reimbursement Criteria during our free Cracking the Code webinar—and show you how to replicate his success. Click the image below to register....its FREE!!