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 Code of Federal Regulations (CFR) Section 422.101.  The rules say that a clinical psychologist who bills Medicare Part B must agree to meet the requirements of 1-3 below.  The clinical psychologist's signature on a Medicare provider/supplier enrollment form indicates his or her agreement.  1. Unless the beneficiary's primary care or attending physician has referred the beneficiary to the clinical psychologist, to inform the beneficiary that it is desirable for the clinical psychologist to consult with the beneficiary's attending or primary care physician (if the beneficiary has such a physician) to consider any conditions contributing to the beneficiary's symptoms 2. If the beneficiary assents to the consultation, in accordance with accepted professional ethical norms and taking into consideration patient confidentiality.  i. To attempt, within a reasonable time after receiving the consent, to consult with the physician; and ii. If attempts to consult directly with the physician are not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the beneficiary.  3. Unless the primary care or attending physician referred the beneficiary to the clinical psychologist, to document, in the beneficiary's medical record, the date the patient consented or declined consent to consultation, the date of consultation, or, if attempts to consult did not succeed, the date and manner of notification to the physician.  You can find this rule in 42 CFR, Section 410.71 - Clinical psychologist services and services and supplies incident to clinical psychologist services.  The rules say that psychotherapy services must meet the following criteria:  1. Individualized treatment plan  Services must be prescribed by a physician and provided under an individualized written plan of treatment established by a physician after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.) (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1)  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 (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).  3. Frequency and duration of service  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 (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1.  You can find this rule in the Local Coverage Determination (LCD) - Outpatient Psychiatry and Psychology Services (L34353) - Effective May 27, 2021.  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.