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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 say that partial hospitalization is a distinct and organized intensive treatment program for patients 
who would otherwise require inpatient psychiatric care. You can find this rule in the Centers for Medicare and 
Medicaid Services (CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 6, Section 70.1 - General (Rev. 10, 05-07-04). 
 
The rules say that patients must meet benefit requirements for receiving the partial hospitalization services as 
defined in 1861(ff) and 1835(a)(2)(F) of the Act. 
 
1. 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. 
2. 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. 
3. 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.  
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.3 - Partial Hospitalization Services 
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10, Implementation: Upon 
Implementation of ICD-10). 
 
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. You can 
find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.3 - Partial Hospitalization Services (Rev. 194, 
Issued: 09-03-14, Effective: Upon Implementation of ICD-10, Implementation: Upon Implementation of ICD-
10). 
 
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.