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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Psychotherapy is defined as the treatment for mental illness and behavioral disturbances in which the clinician
establishes a professional contract with the patient and through definitive therapeutic communication, attempts
to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage
personality growth and development or support current evaluation of functioning. Psychotherapy services
include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement
of family member(s) or others in the treatment process. Although maintenance per se is not covered, helping a
patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may
be covered on a case-by-case basis. These case-by-case considerations must be supported by the evaluation and
a plan with clearly identified goal(s).
Psychotherapy time may include face to face time with family members as long as the patient is present for part
of the service.
To report both E/M and psychotherapy, the two services must be significant and separately identifiable.
1. The type and level of E/M service is selected first based upon the key components of history,
examination, and medical decision-making.
2. Time associated with activities used to meet criteria for the E/M service is not included in the time used
for reporting the psychotherapy service (i.e., time spent on history, examination, and medical decision making
when used for the E/M service is not psychotherapy time). Time may not be used to determine E/M code
selection. Prolonged Services may not be reported when E/M and psychotherapy are reported.
3. A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of
service.
Documentation for Psychotherapy Services
The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers,
such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic
change.
Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a
periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the
medical record.
Prolonged treatment must be well supported by the content of the medical documentation. Documentation must
be present in the medical record supporting the medical necessity for ongoing treatment.
To establish medical necessity of the service, claims must be submitted with a covered diagnosis.
You can find this rule in the Local Coverage Determination (LCD): Psychiatry and Psychology Services
(L34616) effective October 31, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.