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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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that psychotherapy is the treatment for mental illness and behavior 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. 
 
Indications 
1. Psychotherapy will be considered medically reasonable and necessary when the patient has a 
psychiatric illness or is demonstrating emotional or behavioral symptoms sufficient to cause 
inappropriate behavior or maladaptive functioning. 
2. Psychotherapy services must be comprised of clinically recognized therapies that are pertinent to the 
patients illness or condition. The type, frequency and duration of services must be medically necessary 
for the patients condition under accepted practice standards. 
3. There must be a reasonable expectation of improvement in the patients disorder or condition, 
demonstrated by an improved level of functioning, or maintenance of level of functioning where decline 
would otherwise be expected in the case of a disabling mental illness or condition, or chronic mental 
disorders. 
4. The patient must have the capacity to actively participate in all therapies prescribed. 
5. To benefit from psychotherapy, an individual must be cognitively intact to the degree that he/she can 
engage in a meaningful verbal interaction with the therapist. 
6. For patients suffering from dementia, the type and degree of dementia must be taken into account in 
planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a 
patient with dementia, the patients record should support that the patients cognitive level of 
functioning was sufficient to permit the patient to participate meaningfully in the treatment. 
7. The duration of psychotherapy must be individualized for every patient. The provider of service must 
document in the patients record the medical necessity for continued (prolonged) treatments. 
8. Group therapy is defined as psychotherapy administered in a group setting with a trained group leader 
in charge of several patients. The group should not exceed 10 participants and the sessions should be at 
least 45 to 60 minutes in duration. While a video or movie may be used as an adjunct to the sessions, this modality should not be used as a replacement for the therapists active participation and the 
majority of the session should involve the interaction between the participants and the therapist leading 
the session. If group psychotherapy is provided to a patient with dementia, the patients record should 
document that the patients cognitive level of functioning was sufficient to permit the patient to 
participate meaningfully in the treatment. 
9. Family therapy will be considered medically reasonable and necessary only for treatment of the 
Medicare beneficiarys mental illness and not the family members problems. Family therapy is 
appropriate when intervention in the family interactions would be expected to improve or stabilize the 
patients emotional/behavioral disturbance. Family therapy is commonly the major treatment, especially 
for children and also for the elderly. Where both husband and wife are covered by Medicare, such 
therapy may be the most effective treatment for both individuals. 
10. Family psychotherapy without the patient present does not represent routine consultation with staff 
about the patients progress and treatment. Facility staff members are not considered caregivers for 
purposes of this policy; however, caretakers in group-living facilities may be considered caregivers for 
the purpose of this policy. 
 
Limitations 
1. Psychotherapy services are not considered medically reasonable and necessary when documentation 
indicates that dementia has produced a severe enough cognitive defect to prevent establishment of a 
relationship with the therapist, which allows insight-oriented, behavior-modifying or supportive therapy 
to be effective. 
2. Psychotherapy services are never covered for severe and profound mental retardation. Severe mental 
retardation is defined as an IQ 20-34 and profound mental retardation is defined as an IQ under 20. 
3. Psychotherapy services are not considered medically reasonable and necessary when they primarily 
include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, 
play) or social interaction. 
4. Family therapy sessions with a patient whose emotional disturbance would be unaffected by changes in 
the patterns of family interaction (i.e., a comatose patient) would not be considered medically 
reasonable and necessary. Similarly, an emotional disturbance in a family member, which does not 
impact on the Medicare patients status, would not be covered by that patients Medicare benefits. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35101: Psychiatric Codes. 
 
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.