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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.

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).

The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).

The rules say that testing which is intended to diagnose and characterize the neurocognitive effects of medical
disorders that impinge directly or indirectly on the brain. Examples of problems that might lead to
neuropsychological testing are:

- Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild
head injury, anoxic injuries, AIDS dementia)
- Differential diagnosis between psychogenic and neurogenic syndromes
- Delineation of the neurocognitive effects of central nervous system disorders
- Neurocognitive monitoring of recovery or progression of central nervous system disorders; or
- Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies
among individuals with neuropsychiatric disorders.

The content of neuropsychological testing procedures differs from that of psychological testing in that
neuropsychological testing consists primarily of individually administered ability tests that comprehensively
sample cognitive and performance domains that are known to be sensitive to the functional integrity of the
brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions,
constructional praxis, etc.). These procedures are objective and quantitative in nature and require the patient to
directly demonstrate his/her level of competence in a particular cognitive domain.

Patients with dementia represent a very vulnerable population in which co-morbid psychiatric conditions are
common. However, for such a patient to benefit from psychotherapy services requires that their dementia be
mild (e.g., Mini Mental Status Examination score above 15) and that they retain their capacity to recall the
therapeutic encounter from one session, individual or group, to another. This capacity to meaningfully benefit
from psychotherapy must be documented in the medical record. Psychotherapy services are not covered when
documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy
from being effective.

You can find this information in the Local Coverage Determination (LCD): Psychiatry and Psychology
Services (L33632).

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.