Appeal type: unknown
Decision: unknown

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 CFR 422.101.The rules state that psychological testing services must meet the following criteria for coverage:1)Individualized Treatment Plan.The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. 2) Reasonable Expectation of Improvement.Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning.When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary.3) Frequency and Duration of Services.There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, and the patient's response. As long as the evidence shows that the patient continues to show improvement in accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms of medical practice, coverage may be continued.When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated and there is no reasonable expectation of improvement, the outpatient psychiatric services are no longer considered reasonable or medically necessary.Limitations of Coverage:Psychological and Neuropsychological testing is not considered reasonable and necessary when:The patient is not neurologically and cognitively able to participate in a meaningful way in the testing process.Used as screening tests given to the individual or to general populations.Administered for educational or vocational purposes that do not establish medical management.Performed when abnormalities of brain function are not suspected.Used for self-administered or self-scored inventories, or screening tests of cognitive function.Repeated when not required for medical decision-making.Administered when the patient has a substance abuse background and any of the following apply:a. the patient has ongoing substance abuse such that test results would be inaccurate, orb.the patient is currently intoxicatedThe patient has been diagnosed previously with brain dysfunction, such as Alzheimer's diseases and there is no expectation that the testing would impact the patient's medical management. The test is being given solelyas a screening test for Alzheimer's disease -Medicare does not cover this screening for this diagnosis.You can find this information in Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.