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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 patients admitted to a partial hospitalization program (PHP) must be under the care of a 
physician who certifies the need for partial hospitalization and require a minimum of 20 hours per week of 
therapeutic services, as evidenced by their plan of care. The patients also require a comprehensive, structured, 
multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of 
care, because of a mental disorder which severely interferes with multiple areas of daily life, including social, 
vocational, and/or educational functioning. Such dysfunction generally is of an acute nature. In addition, PHP 
patients must be able to cognitively and emotionally participate in the active treatment process, and be capable 
of tolerating the intensity of a PHP program. 
 
The rules say that patients meeting benefit category requirements for Medicare coverage of a PHP comprise 
two groups: those patients who are discharged from an inpatient hospital treatment program, and the PHP is in 
lieu of continued inpatient treatment; or those patients who, in the absence of partial hospitalization, would be 
at reasonable risk of requiring inpatient hospitalization. Where partial hospitalization is used to shorten an 
inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the 
acute, intense, structured combination of services provided by a PHP. Recertification must address the 
continuing serious nature of the patients psychiatric condition requiring active treatment in a PHP. 
 
The rules say that this program of services provides for the diagnosis and active, intensive treatment of the 
individuals serious psychiatric condition and, in combination, are reasonably expected to improve or maintain 
the individuals condition and functional level and prevent relapse or hospitalization. A particular individual 
covered service (described above) as intervention, expected to maintain or improve the individuals condition 
and prevent relapse, may also be included within the plan of care, but the overall intent of the partial program 
admission is to treat the serious presenting psychiatric symptoms. Continued treatment in order to maintain a 
stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., 
intensive outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of 
support necessary to maintain the patient and to prevent hospitalization. 
 
 
 The rules say that patients admitted to a PHP do not require 24 hour per day supervision as provided in an 
inpatient setting, must have an adequate support system to sustain/maintain themselves outside the PHP and 
must not be an imminent danger to themselves or others. Patients admitted to a PHP generally have an acute 
onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the 
Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5, of 
the version of the International Classification of Diseases (ICD) applicable to the service date, which severely 
interferes with multiple areas of daily life. The degree of impairment will be severe enough to require a 
multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from 
participating in an active treatment program. It is the need, as certified by the treating physician, for the 
intensive, structured combination of services provided by the program that constitute active treatment, that are 
necessary to appropriately treat the patients presenting psychiatric condition. 
 
The rules say for patients who do not meet this degree of severity of illness, and for whom partial 
hospitalization services are not necessary for the treatment of a psychiatric condition, professional services 
billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even 
though partial hospitalization services are not. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual Chapter 6  Hospital Services Covered Under Part B, 
Section 70.3 - Partial Hospitalization 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.