Psychiatric Diagnostic Evaluation and Psychotherapy Services

Medically necessary psychiatric diagnostic evaluations (with or without medical services), individual/group/family psychotherapy, psychoanalysis, interactive complexity services, and crisis psychotherapy are covered when the patient has a psychiatric illness or emotional/behavioral symptoms sufficient to cause maladaptive functioning or when baseline functioning is altered. Coverage requires detailed documentation of clinical findings, diagnostic elements, treatment plans with measurable goals (updated generally at least every three months), and, for interactive complexity, explicit documentation of communication barriers and adaptations; several exclusions apply (e.g., severe cognitive deficits preventing effective therapy, routine screening at nursing home admission, psychoanalysis for psychosis).

"Psychiatric diagnostic evaluation is covered when the patient has a psychiatric illness and/or emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive fu..."