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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 state 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: 
1. Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild 
head injury, anoxic injuries, AIDS dementia) 
2. Differential diagnosis between psychogenic and neurogenic syndromes 
3. Delineation of the neurocognitive effects of central nervous system disorders 
4. Neurocognitive monitoring of recovery or progression of central nervous system disorders; or 
5. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders. 
 
Comments: 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. 
Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic 
Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective 
techniques such as the Rorschach or Thematic Apperception Test (TAT) when questions of how brain damage 
or degenerative disease processes (e.g. right hemisphere CVA) may be affecting emotional expression or how 
significant emotional distress or mood impairment might be affecting cognitive function (e.g. question of 
presence of "pseudodementia") arise. 
 
Typically, psychological testing will require from four (4) to six (6) hours to perform, including administration, 
scoring and interpretation. Supporting documentation in the medical record must be present to justify greater 
than 8 hours per patient per evaluation. If the testing is done over several days, the testing time should be combined and reported all on the last date of service. If the testing time exceeds eight (8) hours, medical 
necessity for extended time should be documented. Medical records may be requested. 
 
Limitations: 
 
Severe and profound intellectual disabilities are never covered for psychotherapy services or psychoanalysis. In 
such cases, rehabilitative, evaluation and management (E/M) codes should be reported. 
 
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 rule at the Medicare Local Coverage Determination (LCD) L33632: Psychiatry and 
Psychology Services. 
 
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.