Partial approval and further treatment evidence
What if the insurer approves only some treatment sessions?
A partial approval is still a decision that should be read carefully
The insurer may approve a limited number of sessions, a shorter period or only part of the proposed treatment plan. That does not necessarily mean all future treatment is refused, but it also does not guarantee an extension. Check the written reasons and ask the treating practitioner to provide an updated, progress-based request before the approved sessions run out.
A partial decision can reflect a review point, concern about frequency, missing progress evidence, an alternative treatment proposal or a disputed connection with the accident. The response should address the stated reason rather than treating every limited approval as the same dispute.
If the decision actually refuses the remaining requested sessions, it may carry internal-review or PIC rights. Preserve the complete notice, including attachments and the date received.
Reviewed by Herman Chan, Stephen Young Lawyers
What exactly has the insurer decided?
Compare the clinician’s request with the decision line by line. Identify the number of sessions sought and approved, provider, service type, frequency, fee and period. A decision may approve the current block while asking for a progress report before considering more.
Ask whether the insurer disputes clinical need, accident causation, cost, treatment frequency or evidence of benefit. Those issues need different material. A general statement that treatment is “not supported” should be checked against the evidence cited and the statutory reasons provided.
What should an updated treatment request contain?
The practitioner should report attendance, treatment delivered, measurable change, functional gains, barriers, current goals and the plan for transition or discharge. If improvement is slow, the report should explain why further sessions are expected to provide benefit and whether the approach has changed.
Repeated requests using identical wording can weaken the file. The insurer needs to see why the next block is justified now. Where progress is absent, the practitioner should consider whether another assessment or treatment is clinically appropriate rather than simply request more of the same.
When does partial approval become a dispute?
Guideline 4.106 treats a whole or partial refusal as a written decision. It should state the reasons, identify and provide the relevant information, explain the insurer’s internal-review process and any right to apply to the Personal Injury Commission (PIC), and give information about an Independent Review Office service complaint. A complaint about service does not replace a legal review of the treatment decision.
A PIC medical dispute can concern whether treatment is reasonable and necessary, accident-related or likely to improve recovery. The PIC states that an internal review is ordinarily required first for this kind of medical dispute, unless the insurer fails or declines to conduct it. Use the review rights and triggering date in the actual notice rather than a generic deadline.
Keep treatment and weekly payments separate. A reduction in sessions may affect capacity or recovery, but it does not automatically change PAWE or weekly benefits. Any related capacity decision must be identified and challenged on its own evidence.
Practical next steps
How to respond to a partial approval
Use the approved block while protecting the evidence and review position.
Compare request and decision
Create a short table of what was requested, approved, deferred and refused.
Give the reasons to the practitioner
Ask for a targeted response using current progress and functional measures.
Submit the extension early
Do not wait until the final approved appointment if a new request and report will be needed.
Clarify interim billing
Ask the provider what happens if the current approval ends before the insurer decides the extension.
Protect review rights
If part of the request was refused, retain the full notice and act on the procedure and date applicable to that decision.
Evidence
Partial-approval evidence checklist
The file should show both why the original block was provided and why further sessions are now justified.
- Original treatment request and referral.
- Full written partial-approval decision and attachments.
- Attendance record and treatment delivered.
- Progress measures linked to daily activity, work or recovery goals.
- Updated examination findings and current diagnosis.
- Explanation of barriers, plateau or changed treatment approach.
- Proposed frequency, duration, cost and discharge or self-management plan.
- Independent examination or other insurer evidence cited in the decision.
Common mistakes
- Do not assume a limited approval is either a complete refusal or an unlimited promise of future sessions.
- Do not let approved sessions lapse without documenting attendance and outcome.
- A provider invoice is not a substitute for a progress-based treatment request.
- Do not privately continue expensive treatment without first clarifying who will pay if the extension is refused.
- Do not combine treatment, capacity and weekly-payment objections into one unfocused request.
Timing
Review and evidence timing
The treatment calendar and legal review calendar are different.
- Submit progress material before the approved block ends where further treatment is clinically proposed.
- The insurer should decide a complete treatment request in writing as soon as possible and no later than 10 days after receiving it under Guideline 4.106.
- Keep the date the insurer decision was received; review rights run from the relevant triggering decision, not from the last treatment session.
- Do not rely on a generic dispute deadline. Read the notice and current rules for that treatment decision.
- Lodging a complaint or contacting a lawyer does not itself extend an internal-review or PIC time limit.
Frequently asked questions
- Can I use all approved sessions immediately?
- Follow the approved frequency and clinical plan. Compressing sessions may fall outside the decision and may not be clinically appropriate.
- Must the insurer approve the next block if I improved?
- No automatic rule applies. Improvement is relevant, but the next request must still be reasonable, necessary and related, with a plan for further benefit.
- What if the provider says treatment cannot stop?
- Ask for a report explaining the clinical risk, alternatives and proposed duration. The insurer needs reasoned evidence, not only an assertion.
- Can I dispute the number of sessions?
- Potentially. Check whether the decision refuses part of the request and what internal-review or PIC process applies.
- Will the insurer pay sessions used after approval expired?
- Do not assume so. Obtain written confirmation or understand the private billing risk before continuing.
- What if another treatment would be better?
- The practitioner should explain the changed plan and why it is appropriate. A new service may require its own request and approval.
Related NSW CTP guides
Official sources
- Motor Accident Injuries Act 2017 (NSW), current in-force version
- SIRA Motor Accident Guidelines, current published version
- SIRA Motor Accident Guidelines Part 4: claims
- SIRA: fees and approval for motor crash health services
- Personal Injury Commission: medical disputes
Assessment source: Motor Accident Injuries Act 2017 (NSW), section 3.24 and the current SIRA Motor Accident Guidelines Part 4. The insurer must apply the statutory test and current Guidelines to the individual treatment request and evidence.
Partial approval review
Has the insurer limited the treatment your practitioner requested?
Send the request, partial decision and progress report. We can identify the refused component, evidence gap and applicable review step.
General information only: This page is general NSW CTP information, not legal or medical advice. It does not promise approval, reimbursement, a particular provider or a dispute outcome. Urgent medical care should not be delayed while waiting for legal advice.