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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 partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care 
through active treatment that utilizes a combination of the clinically recognized items and services. The 
treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient 
program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. 
Programs providing primarily social, recreational, or diversionary activities are not considered partial 
hospitalization. 
 
The rules say that the following are covered services: 
1. Individual or group psychotherapy with physicians, psychologists, or other mental health professionals 
authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical 
nurse specialists, certified alcohol and drug counselors); 
2. Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if 
required, must be a component of the physicians treatment plan for the individual; 
3. Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric 
patients; 
4. Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes  
5. Individualized activity therapies that are not primarily recreational or diversionary. These activities must be 
individualized and essential for the treatment of the patients diagnosed condition and for progress toward 
treatment goals; 
6. Family counseling services for which the primary purpose is the treatment of the patients condition; 
7. Patient training and education, to the extent the training and educational activities are closely and clearly 
related to the individuals care and treatment of his/her diagnosed psychiatric condition; and 
8. Medically necessary diagnostic services related to mental health treatment. 
 
Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as 
evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial. It is not 
enough that a patient qualify under the benefit category requirements in or of 1835(a)(2)(F) unless he/she also 
has the need for the active treatment provided by the program of services defined in 1861(ff). It is the need for 
intensive, active treatment of his/her condition to maintain a functional level and to prevent relapse or 
hospitalization, which qualifies the patient to receive the services identified in 1861(ff). 
 The rules also 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. 
 
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. 
 
Patients in PHP may be discharged by either stepping up to an inpatient level of care which would be required 
for patients needing 24-hour supervision, or stepping down to a less intensive level of outpatient care when the 
patients clinical condition improves or stabilizes and he/she no longer requires structured, intensive, 
multimodal treatment. 
 
You can find these rules in the 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.