What Determines Physiotherapy Approval in NSW CTP Claims?
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
In a motor accident compensation claim in New South Wales, approval for physiotherapy treatment is not automatic. Insurers assess each request based on medical evidence and the Motor Accident Injuries Act 2017. The decision depends on whether the treatment is deemed reasonable, necessary and directly related to injuries sustained in the accident. Insurers must follow the Motor Accident Injuries (MAI) Guidelines, which set standards for what constitutes appropriate treatment. Physiotherapy is recognised as a valid form of treatment for musculoskeletal injuries, but approval depends on a clinical assessment by a medical practitioner and a treatment plan that aligns with those guidelines.
How Insurers Evaluate Treatment Requests
Insurers review treatment requests using a structured process. First, the claimant must have a formal diagnosis from a medical practitioner confirming an injury related to the motor accident. The treatment plan must be evidence-based and tailored to the claimant’s injury, recovery progress and functional limitations. Insurers may require a detailed report from the treating physiotherapist outlining the nature of the injury, the proposed treatment, its expected duration and its anticipated benefit to recovery. They may also assess whether the treatment is consistent with the claimant’s recovery trajectory and whether alternative treatments have been considered.
Evidence That Supports Approval
Key evidence that increases the likelihood of approval includes:
- A medical report from a treating practitioner confirming the injury and the need for physiotherapy.
- A written treatment plan from the physiotherapist outlining the goals, frequency and duration of sessions.
- Objective clinical findings such as range of motion limitations, muscle weakness or pain on movement.
- Progress notes showing a measurable response to treatment.
Insurers are more likely to approve treatment when it is part of a structured rehabilitation program and when it supports a return to work, daily activities or physical function. Treatment that appears to be prolonged, inconsistent with recovery progress, or not directly linked to a diagnosed injury may be denied.
Common Reasons for Denial and How to Respond
Insurers may deny a request for physiotherapy if:
- The injury is not medically confirmed as related to the accident.
- The treatment is not considered clinically necessary or proportionate to the injury.
- The treatment plan lacks detail or does not align with the MAI Guidelines.
- The claimant has not provided sufficient medical evidence to support the need.
If a claimant receives a denial, they have the right to request a review. The first step is to contact the insurer in writing and ask for a formal review of the decision. The claimant should submit any additional medical evidence, including updated reports from the treating practitioner or a specialist. If the insurer upholds the denial, the claimant may apply to the State Insurance Regulatory Authority (SIRA) for a review under the Motor Accident Injuries Act 2017. SIRA provides guidance on how to make a formal review application, including the required documentation.
When to Seek Independent Advice
A claimant should consider seeking independent legal or medical advice if:
- The insurer denies treatment without providing a clear reason.
- The claimant’s recovery is not progressing despite consistent treatment.
- The insurer refuses to approve a treatment plan that a specialist has recommended.
Independent medical assessment may be necessary to confirm the injury and treatment need. Legal advice can help clarify rights under the CTP scheme and assist in preparing a formal review application.
Hypothetical Example: A Claimant’s Path to Approval
A 42-year-old office worker was involved in a rear-end collision in Sydney in June 2026. She sustained soft-tissue injuries to her neck and upper back. Her general practitioner referred her to a physiotherapist for a 12-week program focused on posture correction, strengthening and pain management. The insurer initially denied the request, stating the treatment was not supported by sufficient clinical evidence. The claimant obtained a second opinion from an orthopaedic specialist who confirmed the diagnosis and recommended physiotherapy. With the specialist’s report and updated progress notes, she submitted a formal review request. The insurer later approved the treatment after reviewing the new evidence.
Time Limits and Procedural Requirements
There is no fixed deadline for requesting treatment approval, but delays may affect the availability of benefits. Treatment and care benefits are generally available for up to 52 weeks from the date of the accident, unless the claimant has a threshold injury. If a claimant has a threshold injury, weekly benefits and treatment and care benefits are limited to 52 weeks. However, treatment may continue beyond that period if it is part of a long-term rehabilitation plan and approved under a lifetime care arrangement. It is important to act promptly to avoid delays in receiving treatment.
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