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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 Psychological testing includes the administration, interpretation, and scoring of the tests and other medically accepted tests for evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing treatment and prognosis.  Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing.  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. 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.  The following are limitations of testing:  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.  Any diagnostic or psychotherapeutic procedure rendered by a practitioner not practicing within the scope of his/her licensure or other State authorization will be denied.  Psychiatric services billed under the hospital outpatient benefit must be provided in distinct outpatient settings. Outpatient hospital services provided in conjunction with inpatient services, or under the auspices of an excluded inpatient unit, residential treatment center, residential facility, or skilled nursing facility, are not in compliance with Medicare regulations and payment will be denied. Payment may be made for psychiatric services in these settings by individual providers billing Part B.  The following services do not represent reasonable and necessary outpatient psychiatric services: - day care programs, which provide primarily social, recreational, or diversional activities, custodial or respite care; - programs attempting to enhance emotional wellness, e.g., day care programs; - services to a skilled nursing facility resident that should be expected to be provided by the nursing facility staff; - vocational training when services are related solely to specific employment opportunities, work skills, or work settings; - biofeedback training for psychosomatic conditions; - recovery meetings such as Alcoholics Anonymous, 12 Step, Al Anon, Narcotics Anonymous, due to their free availability in the community; - telephone calls to patients, collateral resources and agencies; - evaluation of records, reports, tests, and other data; - explanation of results to family, employers, or others; - preparation of reports for agencies, courts, schools, or insurance companies, etc. for medicolegal or informational purposes; - screening procedures provided routinely to patients without regard to the signs and symptoms of the patient's mental illness. The following services are excluded from the scope of outpatient hospital psychiatric services: - services to hospital inpatients; - meals, transportation; - supervision or administration of self-administered medications and supplying medications for home use. Evaluations of the mental status that can be performed within the clinical interview, such as a list of questions concerning symptoms of depression or organic brain syndrome, corresponding to brief questionnaires such as the Folstein Mini Mental Status Examination or the Beck Depression Scale, should not be billed as psychological testing, but are considered included in the clinical interview.  Adjustment reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for psychological testing. However, if a more serious mood disorder (e.g., major depression) is suspected upon admission to a nursing facility, psychological or neuropsychological testing may be indicated for differential diagnostic purposes and to develop appropriate treatment planning.  Routine testing of nursing home patients is considered screening and is not covered.  Each psychological test administered must be individually medically necessary. A standard battery of tests is only medically necessary if each individual test in the battery is medically necessary.  Psychological testing should not be reported by the treating physician for only reading the testing report generated by another clinician or explaining the results of a neuropsychological assessment generated by another clinician to the patient or family. Payment for these services is included in the payment for other services rendered to the patient, including both services provided by neuropsychologists and psychologists and evaluation and management services billed provided by physicians, e.g., neurologists, rehabilitation medicine physicians, and psychiatrists.  Psychological testing is limited to physicians, clinical psychologists, and on a limited basis, to qualified non-physician practitioners (e.g., speech language pathologists for aphasia evaluation).  You can find these rules in the Local Coverage Determination (LCD) for Psychiatry and Psychology Services, L33632.  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.