By Jordan Rau, KFF Health News

Mari Villar was slammed by a car that jumped the curb, breaking her legs and collapsing a lung. Amy Paulo was in pain from a femur surgery that wasn’t healing properly. Katie Kriegshauser suffered organ failure during pregnancy, weakening her so much that she couldn’t lift her baby daughter.

All went to physical therapy, but their health insurers stopped paying before any could walk without assistance. Paulo spent nearly $1,500 out of her own pocket for more sessions.

Mari Villar at a therapy session with physical therapist C. Ryan Coxe at Chicago’ s Shirley Ryan AbilityLab. (Jim Vondruska/KFF Health News/TNS)

Millions of Americans rely on physical and occupational therapists to regain strength and motor skills after operations, diseases, and injuries. But recoveries are routinely stymied by a widespread constraint in health insurance policies: rigid caps on therapy sessions.

Insurers frequently limit such sessions to as few as 20 a year, a KFF Health News examination finds, even for people with severe damage such as spinal cord injuries and strokes, who may need months of treatment, multiple times a week. Patients can face a bind: Without therapy, they can’t return to work, but without working, they can’t afford the therapy.

Paulo said she pressed her insurer for more sessions, to no avail. “I said, ‘I’m in pain. I need the services. Is there anything I can do?’” she recalled. “They said, no, they can’t override the hard limit for the plan.”

Mari Villar still can’ t manipulate her right foot nearly two years after a hit-and-run driver smashed into her. (Jim Vondruska/KFF Health News/TNS)

A typical physical therapy session for a privately insured patient to improve daily functioning costs $192 on average, according to the Health Care Cost Institute. Most run from a half hour to an hour.

Insurers say annual visit limits help keep down costs, and therefore premiums, and are intended to prevent therapists from continuing treatment when patients are no longer improving. They say most injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority.

Atul Patel, a physiatrist in Overland Park, Kansas, and the treasurer of the American Academy of Physical Medicine and Rehabilitation, said insurers’ desire to prevent gratuitous therapy is understandable but has “gone too far.”

“Most patients get way less therapy than they would actually benefit from,” he said.

Mari Villar has had 11 operations to repair the damage caused when a car crashed into her on a Chicago sidewalk, broke both her legs, and damaged her liver, colon, and one of her lungs. Here she displays one of her surgical scars. (Jim Vondruska/KFF Health News/TNS)

Hard caps on rehab endure in part because of an omission in the Affordable Care Act. While that law required insurers to cover rehab and barred them from setting spending restrictions on a patient’s medical care, it did not prohibit establishing a maximum number of therapy sessions a year.

More than 29,000 ACA health plans — nearly 4 in 5 — limit the annual number of physical therapy sessions, according to a KFF Health News analysis of plans sold last year to individuals and small businesses. Caps generally ranged from 20 to 60 visits; the most common was 20 a year.

Health plans provided by employers often have limits of 20 or 30 sessions as well, said Cori Uccello, senior health fellow at the American Academy of Actuaries.

“It’s the gross reality in America right now,” said Sam Porritt, chairman of the Falling Forward Foundation, a Kansas-based philanthropy that has paid for therapy for about 200 patients who exhausted their insurance over the past decade. “No one knows about this except people in the industry. You find out about it when tragedy hits.”

Even in plans with no caps, patients are not guaranteed unlimited treatment. Therapists say insurers repeatedly require prior authorization, demanding a new request every two or three visits. Insurers frequently deny additional sessions if they believe there hasn’t been improvement.

“We’re seeing a lot of arbitrary denials just to see if you’ll appeal,” said Gwen Simons, a lawyer in Scarborough, Maine, who represents therapy practices. “That’s the point where the therapist throws up their hands.”

‘Couldn’t pick her up’

Katie Kriegshauser, a 37-year-old psychologist from Kansas City, Missouri, developed pregnancy complications that shut down her liver, pancreas, and kidneys in November 2023. After giving birth to her daughter, she spent more than three months in a hospital, undergoing multiple surgeries and losing more than 40 pounds so quickly that doctors suspected her nerves became damaged from compression. Her neurologist told her he doubted she would ever walk again.

Kriegshauser’s UnitedHealthcare insurance plan allowed 30 visits at Ability KC, a rehabilitation clinic in Kansas City. She burned through them in six weeks in 2024 because she needed both physical therapy, to regain her mobility, and occupational therapy, for daily tasks such as getting dressed.

“At that point I was starting to use the walker from being completely in the wheelchair,” Kriegshauser recalled. She said she wasn’t strong enough to change her daughter’s diaper. “I couldn’t pick her up out of her crib or put her down to sleep,” she said.

The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms. “A huge amount of progress happened in that period after my insurance ran out,” she said.

In an unsigned statement, UnitedHealthcare said it covered the services that were included in Kriegshauser’s health plan. The company declined to permit an official to discuss its policies on the record because of security concerns.

A shattered teenager

Patients who need therapy near the start of a health plan’s year are more likely to run out of visits. Mari Villar was 15 and had been walking with high school friends to get a bite to eat in May 2023 when a car leaped over a curb and smashed into her before the driver sped away.

The accident broke both her legs, lacerated her liver, damaged her colon, severed an artery in her right leg, and collapsed her lung. She has undergone 11 operations, including emergency exploratory surgery to stop internal bleeding, four angioplasties, and the installation of screws and plates to hold her leg bones together.

Mari Villar at a therapy session with physical therapist C. Ryan Coxe at Chicago’ s Shirley Ryan AbilityLab. (Jim Vondruska/KFF Health News/TNS)

Villar spent nearly a month in Shirley Ryan AbilityLab’s hospital in Chicago. She was discharged after her mother’s insurer, Blue Cross and Blue Shield of Illinois, denied her physician’s request for five more days, making her more reliant on outpatient therapy, according to records shared by her mother, Megan Bracamontes.

Villar began going to one of Shirley Ryan’s outpatient clinics, but by the end of 2023, she had used up the 30 physical therapy and 30 occupational therapy visits the Blue Cross plan allowed. Because the plan ran from July to June, she had no sessions left for the first half of 2024.

“I couldn’t do much,” Villar said. “I made lots of progress there, but I was still on crutches.”

Megan Bracamontes’ health insurance allows for only 30 physical therapy sessions a year per person. Her daughter Mari Villar (left) has needed extensive PT after she was hit by a car in 2023. (Jim Vondruska/KFF Health News/TNS)

Dave Van de Walle, a Blue Cross spokesperson, said in an email that the insurer does not comment on individual cases. Razia Hashmi, vice president for clinical affairs at the Blue Cross Blue Shield Association, said in a written statement that patients who have run out of sessions should “explore alternative treatment plans” including home exercises.

Villar received some extra sessions from the Falling Forward Foundation. While her plan year has reset, Villar is postponing most therapy sessions until after her next surgery so she will be less likely to run out again. Bracamontes said her daughter still can’t feel or move her right foot and needs three more operations: one to relieve nerve pain, and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right.

“Therapy caps are very unfair because everyone’s situation is different,” Villar said. “I really depend on my sessions to get me to a new normalcy. And not having that and going through all these procedures is scary to think about.”

Rationing therapy

Most people who use all their sessions either stop going or pay out-of-pocket for extra therapy.

Amy Paulo, a 34-year-old Massachusetts woman recovering from two operations on her left leg, maxed out the 40 visits covered by Blue Cross Blue Shield of Massachusetts in 2024, so she spent $1,445 out-of-pocket for 17 therapy sessions.

Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg — the difference a consequence of juvenile arthritis. Her recovery was prolonged, she said, because her femur didn’t heal properly after one of the operations, in which surgeons cut out the middle of her femur and put a rod in its place.

“I went ballistic on Blue Cross many, many times,” said Paulo, who works with developmentally delayed children.”

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Amy McHugh, a Blue Cross spokesperson, declined to discuss Paulo’s case. In an email, she said most employers who hire Blue Cross to administer their health benefits choose plans with “our standard” 60-visit limit, which she said is more generous than most insurers offer, but some employers “choose to allow for more or fewer visits per year.”

Paulo said she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she’ll need more help after an upcoming operation on her leg.

“We had to plan to save my visits for this surgery, as ridiculous as it sounds,” she said.

Medicare is more generous

People with commercial insurance plans face more hurdles than those on Medicare, which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document medical necessity. This year the limits are $2,410 for physical and speech therapy and $2,410 for occupational therapy.

Private Medicare Advantage plans don’t have visit or dollar caps, but they often require prior authorization every few visits. The U.S. Senate Permanent Subcommittee on Investigations found last year that MA plans deny requests for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other medical services.

Therapists say many commercial plans require prior authorization and mete out approvals parsimoniously. Insurers often make therapists submit detailed notes, sometimes for each session, documenting patients’ treatment plans, goals, and test results showing how well they perform each exercise.

“It’s a battle of getting visits,” said Jackee Ndwaru, an occupational therapist in Jacksonville, Florida. “If you can’t show progress they’re not going to approve.”

An insurer overruled

Marjorie Haney’s insurance plan covered 20 therapy sessions a year, but Anthem Blue Cross Blue Shield approved only a few visits at a time for the rotator cuff she tore in a bike accident in Maine. After 13 visits in 2021, Anthem refused to approve more, writing that her medical records “do not show you made progress with specific daily tasks,” according to the denial letter.

Haney, a physical therapist herself, said the decision made no sense because at that stage of her recovery, the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion.

“I went through those visits like they were water,” Haney, now 57, said. “My range was getting better, but functionally I couldn’t use my arm to lift things.”

Haney appealed to Maine’s insurance bureau for an independent review. In its report overturning Anthem’s decision, the bureau’s physician consultant, William Barreto, concluded that Haney had made “substantial improvement” — she no longer needed a shoulder sling and was able to return to work with restrictions. Barreto also noted that nothing in Anthem’s policy required progress with specific daily tasks, which was the basis for Anthem’s refusal.

“Given the member’s substantial restriction in active range of motion and inability to begin strengthening exercises, there is remaining deficit that requires the skills and training of a qualified physical therapist,” the report said.

Anthem said it requires repeated assessments before authorizing additional visits “to ensure the member is receiving the right care for the right period of time based on his or her care needs.” In the statement provided by Stephanie DuBois, an Anthem spokesperson, the insurer said this process “also helps prevent members from using up all their covered treatment benefits too quickly, especially if they don’t end up needing the maximum number of therapy visits.”

In 2023, Maine passed a law banning prior authorization for the first 12 rehab visits, making it one of the few states to curb insurer limitations on physical therapy. The law doesn’t protect residents with plans based in other states or plans from a Maine employer who self-insures.

Haney said after she won her appeal, she spaced out the sessions her plan permitted by going once weekly. “I got another month,” she said, “and I stretched it out to six weeks.”

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

The first three days of the Trash Emergency were cloaked in gloom. We weren’t under a watch. We were in a warning. Not exactly despair, but resignation set in, as though sheltering in the basement and sprinkling the children with holy water were to be the accommodating ministrations.

The collection of our bins was in jeopardy.

That is, the collection of our bins was in jeopardy until the mayor declared a Trash Emergency, a power we didn’t know the mayor even had nor had the power ever been previously used.

It wasn’t an entirely chaotic start. After the new hauler, FCC Environmental Services, came through, some bins were tipped over in the street, some were on their backs in the yard and couldn’t get up. But certainly, a disaster was averted and we were spared photographs in the newspapers of uncollected piles of garbage, like we sometimes see from Rome or New York.

Unfortunately, the Trash Emergency is good for only 90 days, unless mayors have a post-trash-emergency emergency they can pull from their vest. A recent communication breakdown appears to be the root of the problem, although a great many of us looking for the problem would go back seven years or so when the city fixed a system that wasn’t broken. Out went the family-owned haulers and in came only five haulers, all to ostensibly reduce noise and save the Earth, neither of which happened anyway.

And then, just when we were finally getting to at least a hand-waving familiarity with one of the big five haulers, out they go in favor of FCC Environmental, which won the current bidding process. That was last year, August, even months ago.

FCC bought property at the foot of Randolph Avenue at Shepard Road. It’s a big brown field surrounded by a chain-link fence. They bought the land after a developer probably gave up on it because not many developers want to develop in St. Paul with rent control breathing down their necks. It’s been a big brown field for as long as anyone can remember. This is where FCC would dispatch trucks, wash them and fuel them with compressed natural gas.

FCC had it clarified from the city zoning administrator that FCC’s intention for the land fit with I-1 zoning, light industrial, similar to the uses of a public works yard. They were going to build a headquarters and pay property taxes.

Good to go!

Whoa, hold up a minute. The West Seventh/Fort Road Federation got the ear of the city Planning Commission and appealed, but the commission supported the stance taken by the city staff.

The neighborhood advocates then went to the least diverse city council in America, who probably had to put down a resolution they were studying to preserve sand in the Polynesian Islands, and the next thing you know, the council voted to uphold the neighborhood federation’s appeal and right on the cusp of its April 1 start date, FCC had no base of operations.

A war within a war seems to have developed. Mayor Melvin Carter told the council that they had plunged the city into crisis. He called the Trash Emergency. That was for three days, but the council did vote to allow a 90-day Trash Emergency. Council President Rebecca Noecker, presumably smarting, told the mayor and FCC that they had better use the 90 days to find a new site for that $25 million dispatch center.

If you were dropped out of a spaceship having never seen Earth, and shown the land in question, you’d say, “This looks like a place where a trash-hauling company might operate.”

But not in St. Paul. Not to worry. We’re playing with house money. Still more than 80 days to go with the Trash Emergency, all the time in the world.

Joe Soucheray can be reached at jsoucheray@pioneerpress.com. Soucheray’s “Garage Logic” podcast can be heard at garagelogic.com.

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Letters: St. Paul’s West End has long had to fight for its character

F. Scott Fitzgerald fans across the globe are celebrating the centennial of “The Great Gatsby” this year.

From Princeton University, Fitzgerald’s alma mater, to the French Riviera, where he worked on the novel, this milestone anniversary will be marked with all kinds of “Gatsby”-themed events.

Here in the author’s birthplace, St. Paul will host parties, exhibits, performances and more — even a live reading of the entire novel at the Minnesota History Center on Thursday.

F. Scott Fitzgerald in the third-floor bedroom of his parents’ residence at 599 Summit Ave., where he wrote “This Side of Paradise.” (From the “Sight Unseen” exhibit at the George Latimer Library in downtown St. Paul)

But all this fuss over “Gatsby” would have been hard to imagine when it first landed on store shelves 100 years ago. After receiving mixed reviews from literary critics, the book sold poorly.

Fitzgerald died in 1940 believing it was a flop, said Maureen Corrigan, book critic for NPR’s Fresh Air program and author of “So We Read On: How ‘The Great Gatsby’ Came to Be and Why it Endures.”

“He really did think it was a failure,” Corrigan said. “The torture was he knew he had written a great book, and he wanted people to read it. … I do think it broke his heart that it wasn’t received as anything special by a lot of people.”

In St. Paul, Fitzgerald’s hometown newspapers did little to help, offering only qualified praise of his masterpiece in their 1925 reviews.

It was “the best of his novels,” but “not of the greatest importance.” It was “never dull for a moment,” but full of “stupid” characters and “very little” plot.

The book’s lukewarm reception in the local press may not be surprising given its author’s complicated relationship with St. Paul, said Mark Taylor, a Fitzgerald historian who gives walking tours of his old haunts along Summit Avenue.

“It seems like there was a reluctance on the part of St. Paul to embrace Fitzgerald during his lifetime … perhaps wanting to distance the city from this person who is known for having led kind of a fast life,” Taylor said.

‘They raised eyebrows’

Fitzgerald had made a triumphant return to the city that shaped him four years before “Gatsby” was published.

Already the acclaimed author of “This Side of Paradise,” he was working on revisions to “The Beautiful and Damned” in summer 1921 when he moved back to his hometown with his pregnant wife, Zelda.

F. Scott and Zelda Fitzgerald at Dellwood on White Bear Lake the month before their daughter, Scottie, was born. (Courtesy of the Minnesota Historical Society)

The Fitzgeralds were by then national celebrities and avatars of the Roaring Twenties, famous for their glamorous, gin-soaked lifestyle in New York.

“Fitzgerald was one of the first people who was famous for being famous,” said Dave Page, a St. Paul historian, of the author’s life and career. “He and Zelda understood that they could monetize their fame.”

They became known in St. Paul for wild parties that earned them a handful of eviction notices from a series of fashionable lodgings — and perhaps the disapproval of their neighbors.

“They raised eyebrows, that’s for sure,” Page said. “St. Paul was a very conservative, Catholic town. You just didn’t do that kind of stuff. You didn’t make a big deal out of yourself. It was very Victorian, and the Fitzgeralds were post-Victorian.”

Thomas Boyd, a friend of Fitzgerald’s who was then the literary editor of the St. Paul Daily News, wrote in March 1922 that the author appeared to have “ruffled the composure of his fellow townsmen.”

After the successful release of “The Beautiful and the Damned,” Fitzgerald began to workshop the story that would become “Gatsby” that summer at a rented house in White Bear Lake, but he wouldn’t write it here.

He and Zelda had both had enough of Minnesota, and they moved back to New York with their infant daughter, Scottie, that fall. They would never return to St. Paul.

Fitzgerald carefully crafted “Gatsby” over the next couple of years, infusing his Jazz Age melodrama with artful commentary on class, wealth, ambition and the American dream.

“Fitzgerald thought ‘Gatsby’ was going to be the novel that would break all the records,” Corrigan said. “It was going to top ‘This Side of Paradise.’ It was going to raise his literary reputation even higher. … And it didn’t.”

Not-so-great ‘Gatsby?’

Critics greeted “Gatsby” with ambivalence when it was released on April 10, 1925. Many reviews praised Fitzgerald’s elegant prose but dismissed the book’s literary significance.

The first mention to appear in the St. Paul papers was an unsigned review in the Pioneer Press on April 19, which called it by “far the best of his novels.” Its praise, however, was a bit backhanded.

The dust jacket of “The Great Gatsby.” (Courtesy image)

“While the work itself is not of the greatest importance, it does mark a distinct advance in the author’s command of his medium,” the anonymous critic wrote.

The St. Paul Daily News was even less generous in its review on May 3, despite admitting that “Gatsby” was “never dull for a moment.”

“Of plot there is very little, save for some hectic love affairs that are not above reproach, the author’s aim and interest all being centered on Gatsby himself,” wrote Clifford Trembley, the paper’s books editor. “Personally I don’t think the fellow was worth so much effort.”

That same day, the Pioneer Press returned to “Gatsby,” publishing a Chicago Tribune review by H.L. Mencken that — despite praising the “charm and beauty” of Fitzgerald’s writing — called the book itself “no more than a glorified anecdote” and “obviously unimportant.”

Fitzgerald was wounded by the critical indifference to his novel — and by its lackluster sales. While Fitzgerald’s first two novels had each sold about 50,000 copies, “Gatsby” managed a meager 21,000.

When he died in 1940, Fitzgerald and his work were largely forgotten, evidenced by the many unsold copies of “Gatsby” gathering dust in his publisher’s warehouse, Corrigan said.

Fitzgerald was eulogized in the St. Paul Dispatch by his friend James Gray, the newspaper’s literary and drama critic, who seemed to sense the book’s significance.

“He wrote one novel, ‘The Great Gatsby,’ which reveals his gift at its most urbane, sensitive and imaginative,” Gray wrote. “It is one of those small masterpieces which inevitably misses tremendous popular success because its implications are more subtle than the casual public cares to disentangle from a melodramatic story.”

“Perhaps some day it will be rediscovered,” he hoped. He didn’t have to wait long.

New life for an ‘old sport’

The United States entered World War II almost exactly a year after Fitzgerald’s death — and it would help revive his masterpiece.

A consortium of booksellers and publishers decided American troops overseas would benefit from some free reading material they could carry with them into battle. Their answer was the Armed Services Editions — hundreds of titles printed on cheap paper and handed out to GIs, who devoured them in their downtime.

Melting snow beads off a statue of F. Scott Fitzgerald in St. Paul’s Rice park on Nov. 6, 2013. The statue was unveiled in 1996 as part of a celebration of the author’s 100th birthday. (John Doman / Pioneer Press)

Roughly 155,000 copies of “The Great Gatsby” found their way into the hands of American servicemen through the ASE series — several times more than had been sold during Fitzgerald’s lifetime.

The book’s popularity surged in post-war America, and a 1951 biography of its author by Arthur Mizener helped bring Fitzgerald and his work back into the public consciousness.

Fans of the late St. Paulite began making pilgrimages to his hometown. Ethel Cline, who lived in the Summit Avenue row house where Fitzgerald finished writing “This Side of Paradise,” told the Pioneer Press in 1958 that “she has received numerous callers curious about Fitzgerald’s days in St. Paul.”

Over the years, the city has fully embraced its association with the famous author, and “Gatsby” — his “glorified anecdote” — has become one of the most acclaimed novels of all time.

“It’s our greatest ‘great American novel’ about class and the hidden ways in which that American promise doesn’t extend equally to everyone,” Corrigan said. “Gatsby tells us the American dream is a mirage, but at the same time, we reach for it. Fitzgerald said the novel is about aspiration. And he thinks aspiration is beautiful.”

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Photo gallery: Throwback Thursday

To celebrate the 100th anniversary of “The Great Gatsby” on Thursday, a handful of F. Scott Fitzgerald enthusiasts will read the entire novel aloud at the Minnesota History Center in St. Paul.

Published on April 10, 1925, “Gatsby” is the St. Paul native’s best-known work and widely regarded as one of the greatest novels of all time.

Scheduled to run from 1 to 7:30 p.m., the live reading is one of several events planned by the Friends of the St. Paul Public Library commemorating “Gatsby’s” centennial in its author’s hometown that will “revisit the book and consider how its themes apply today,” the organization’s website says.

Upstairs in the History Center’s Gale Family Library, several Fitzgerald-related items from the collection of the Minnesota Historical Society are on display.

Later on that evening, Storyline Books will host a “Gatsby”-themed cocktail party at 1881 Eating House in Union Depot. Celtic Junction in Midway will host a “Gatsby Speakeasy Dance” on Friday night, complete with a live jazz band.

The Friends’ series of “Gatsby” events will continue throughout the rest of the year and include these events:

April 15: A book club discussion of “The Great Gatsby – A Graphic Novel Adaptation” by Katherine Woodman Maynard at Urban Growler in St. Paul.

May 1 to May 31: Books from Minnesota women authors of the 1920s will be on display at George Latimer Central Library in St. Paul.

Sept. 13 to March 22, 2026: “Gatsby at 100,” an exhibit at the Minneapolis Institute of Art in Minneapolis.

Sept. 19 to Sept. 22: “The Last Flapper,” a one-woman show by William Luce based on the writings of Zelda Fitzgerald, performed by Monette Magrath at Landmark Center in St. Paul.

Nov. 9: “Teaching The Great Gatsby,” an online panel discussion with teachers from around the United States.

A full schedule of events can be found on the Friends website at thefriends.org/fitzgerald.

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