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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 Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various 
mental health disorders and/or diseases. 
 
References to providers throughout this policy include physicians, and non-physicians, such as clinical 
psychologists, independent psychologist, nurse practitioners, clinical nurse specialists and physician assistants 
when the services performed are within the scope of their clinical practice/education and authorized under the 
state law. 
 
Psychiatry Services with Evaluation and Management (E/M) 
Some psychiatry services may be reported with evaluation and management (E/M) services or other services 
when performed. An E/M code may be used to report evaluation and management services alone (no other 
service reported that day) or used to report an E/M service with psychotherapy. An E/M service is based on the 
physicians work and includes services medically necessary to evaluate and treat the patient. 
 
Psychiatric Diagnostic Evaluation 
A psychiatric diagnostic evaluation is an integrated assessment that includes history, mental status and 
recommendations. It may include communicating with the family and ordering further diagnostic studies. A 
psychiatric diagnostic evaluation with medical services includes a psychiatric diagnostic evaluation and a 
medical assessment. It may require a physical exam, communication with the family, prescription medications 
and ordering laboratory or other diagnostic studies. A psychiatric diagnostic evaluation with medical services 
also includes physical examination elements. 
 
Patients may need an evaluation and diagnosis by a multidisciplinary team prior to implantation of peripheral 
and central nervous system stimulators for chronic intractable pain. (See NCD 160.7 Electrical Nerve 
Stimulators.) 
 
The following information pertains to both psychiatric diagnostic evaluation; and psychiatric diagnostic 
evaluation with medical services: 
 
        Cannot be reported with an E/M code on the same day by the same provider 
        Cannot be reported with a psychotherapy service code on the same day 
        May only be reported once per day 
        May be reported more than once for a patient when separate evaluations are conducted with the patient and other informants (i.e., family members, guardians, significant others) on different days. This service is 
considered medically necessary once every 6 months per episode of illness. *However, if reported more than 
once per episode of illness, documentation will be required for the establishment of medical necessity. 
        In certain circumstances family members, guardians, or significant others may be seen in lieu of the 
patient 
 
You can find this information in the Local Coverage Determination (LCD) Psychiatry and Psychology Services 
L34616. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.