There should hopefully be a LCD from the MAC. For instance this an excerpt from LCD [FONT="]L33632 from [/FONT][FONT="]National Government Services, Inc.[/FONT]
Coverage Criteria.[FONT="]The services must meet the following criteria:[/FONT]
Individualized Treatment Plan.[FONT="] The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.) [/FONT]
Reasonable Expectation of Improvement.[FONT="] Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, [/FONT]and[FONT="] improve or maintain the patient's level of functioning (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT="], Chapter 6, Section 70.1).[/FONT]
It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that if treatment services were withdrawn the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met[FONT="] (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT="], Chapter 6, Section 70.1).[/FONT]
Some patients may undergo a course of treatment which increases their level of functioning, but then reach a point where further significant increase is not expected[FONT="] (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT="], Chapter 6, Section 70.1). When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary.[/FONT]
Frequency and Duration of Services.[FONT="] There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, and the patient's response. As long as the evidence shows that the patient continues to show improvement in accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms of medical practice, coverage may be continued (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT="], Chapter 6, Section 70.1).[/FONT]
[FONT="]When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated and there is no reasonable expectation of improvement, the outpatient psychiatric services are no longer considered reasonable or medically necessary.[/FONT]