Neuropsychological Testing Form
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Neuropsychological Testing Medical Guideline
Service: Neuropsychological Testing
PUM 250-0006
Medical Guideline Committee Approval Q2-06/2025 Effective Date 09/01/2025
Coverage for Neuropsychological testing may vary across plans. Refer to the member’s benefit plan document for coverage details.
Description:
Neuropsychological tests (NPT) are evaluations designed to determine the functional consequences of known or suspected brain injury or abnormality through testing of the neurocognitive domains responsible for language, perception, memory, learning, problem solving and adaptation. Neuropsychological test batteries usually involve extensive evaluation of multiple cognitive domains (e.g., attention, orientation, executive function, verbal memory, spatial memory, language, calculations, mental flexibility, and conceptualization).
These tests are carried out on patients who have suffered neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. They are standardized, objective and quantitative in nature and require patients to directly demonstrate their level of competence in a particular cognitive domain. They are not a substitution for clinical interviews, medical, neurologic, or psychological examinations, or other diagnostic procedures used to diagnose neuropathology. Rather, when used judiciously in patients with particular neuropsychological problems, they can be an important tool in making specific diagnoses or prognoses after neurologic injury, to aid in treatment planning, and to address questions regarding treatment goals, efficacy, and patient disposition.
Neuropsychological testing is also used to differentiate psychiatric disorders from neurological disorders. Determining what specific brain functions are compromised, as well as which cognitive functions are intact, can help differentiate between the two types of disorders and predict the effects of remediation.
Concussion and Post-concussion Syndrome: Neuropsychological testing is increasingly used in assessment and management of sport-related concussion to assist in return to play decisions. There is some evidence that testing such as the ImPACT test may help to improve the accuracy of cognitive assessment post-concussion. There is poor evidence that testing is prognostic for rate of recovery or that it should be used alone as an indicator for return to play or school. There is insufficient evidence that baseline tests alone influence physician decision-making or management of concussion. The validity of pre-competition testing is controversial.
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Neuropsychological testing and attention deficit hyperactivity disorder (ADHD): Diagnosis of ADHD can be accomplished using clinical evaluation procedures including an interview, review of the patient’s medical, psychological, academic, and/or employment records, information from collateral sources, screening inventories, substance abuse history, and physical exam. Neurologic conditions that can mimic or co-exist with ADHD can be distinguished from ADHD through history and medical examination and specialized psychometric and medical testing. Neuropsychological testing may be indicated in rare circumstances.
Indications of Coverage:
Note: The provider performing the testing must be a covered provider for the particular illness or injury under the plan, depending on the condition that is being evaluated.
A. Neurobehavioral status exam is considered medically necessary to evaluate possible issues with cognitive functioning, determine the need for neuropsychological testing, and/ or evaluate the treatment efficacy of a cognitive issue previously diagnosed (not an all- inclusive list). *The neurobehavioral status exam does not require medical necessity review.
B. Neuropsychological testing (NPT) is considered medically necessary for the purpose of directing further medical care when ALL of the following criteria are met:
Documentation of a neurobehavioral status exam or thorough evaluation by a neurologist, psychiatrist, or psychologist indicates the need for NPT.
When at least one medical condition or situation is present, such as, but not limited to:
a. Head injury (open or closed)/traumatic brain injury.
b. Stroke or cerebral vascular injury (e.g., brain aneurysm, subdural hematoma).
c. Brain tumor
d. Cerebral anoxic or hypoxic episode.
e. Severe central nervous system infection.
f. Suspected Autism Spectrum Disorder (prior to treatment and to evaluate/compare testing following at least a year of treatment).
g. Neoplasm or vascular injury of the central nervous system.
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h. Neurodegenerative disorders (e.g., Lewy body dementia, primary progressive aphasia, Alzheimer’s disease, vascular dementia).
i. Demyelinating diseases (e.g., multiple sclerosis)
j. Epilepsy and seizure disorders
k. Extrapyramidal diseases (e.g., Parkinson’s, Huntington’s)
l. Metabolic encephalopathy after disease stabilization.
m. Exposure to agents known to be associated with neurodysfunction, such
as intrathecal methotrexate, cranial irradiation, lead poisoning).
Occupational hazards such as chronic solvent exposure, if a covered
benefit.
n. A psychiatric diagnosis has been ruled out or is not responsive to appropriate treatment and testing is requested to provide a distinction between a psychiatric and neurologic syndrome that is affecting neurocognitive function.
o. The presence of unusual, complex, or co-morbid symptoms requiring clarification that only can be accomplished through neuropsychological testing (e.g., worsening symptoms with appropriate treatment for the presumed diagnosis, or differentiating medication-related delirium from a progressive process).
p. Complicated Attention-deficit/hyperactivity disorder (ADHD) when ALL of the following are present:
i. Specific neurocognitive behavioral deficits related to ADHD that need to be evaluated; and ii. Testing has been recommended by a physician and is related or secondary to a known or suspected organic/medical condition resulting from brain injury or disease process, including one or more of the following:
a. Concussion or traumatic brain injury b. History of CNS (central nervous system) infection c. Intractable seizure disorder d. Cancer treatment effects e. Genetic disorders f. Inborn errors of metabolism g. History of stroke, hypoxic-ischemic encephalopathy, or intracranial vascular malformation
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The neuropsychological tests employed are likely to produce the diagnostic and treatment clarification required AND at least ONE of the following conditions or situations is present:
a. When there has been a significant mental status change that is not due to a metabolic disorder (such as a diabetic hypoglycemic episode) and the change has not responded to acute medical therapy.
b. When there has been a significant behavioral deficit or change, memory loss, inability to perform simple calculations or abstract tasks, organic brain injury, sensory illusions, or other serious circumscribed cognitive deficits, AND a comprehensive medical and psychological evaluation has been unable to establish a diagnosis.
c. Re-evaluation of an individual with decreasing cognitive function is requested due to a neurological disorder if the results are intended to guide treatment.
d. A comprehensive evaluation of a child with suspected autism spectrum disorder to assist in establishing the proper diagnosis and treatment plan.
NOTE: Time needed for NPT testing varies depending upon the number of tests performed as well as the cognitive and health status of the individual being tested. More than 10 hours of testing will be considered not medically necessary. Requests exceeding 10 hours will require Medical Director review.
C. Post-concussion evaluation: Non-baseline NPT testing (e.g., ImPACT) by a physician, psychologist, or licensed mental health professional for management of concussion is considered medically necessary.
Limitations of Coverage:
Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”
A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.
B. If used for a condition/diagnosis other than as listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven at affect health outcomes.
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C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.
D. Computerized or computer-based cognitive testing or neuropsychological assessment devices (such as Creyos, Cognitrax or Neurotrax) are considered experimental, investigational and unproven.
E. Greater than 10 hours of testing will be considered not medically necessary.
F. If not specified as a health plan exclusion, NPT is considered NOT medically necessary in any established (OR an existing) situation:
There is no documentation of thorough medical evaluation by a physician (primary care, specialty, or both) prior to the request.
Request is solely to confirm the working diagnosis and treatment plan.
There is no documentation of how the testing will benefit the development of the treatment plan.
Uncomplicated attention deficit disorder with or without hyperactivity
(ADD/ADHD).Testing is for requested educational purposes, such as assessment of learning style, learning disability, academic ability, development of an educational plan, or for uncomplicated attention deficit disorder.
Testing is for the purpose of obtaining or maintaining employment or improving job performance.
Testing is ordered or requested pursuant to a condition of parole, probation, or in any way related to judicial or legal purposes.
Testing is required or requested by a third party, such as a school or place of employment.
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Testing is solely for documenting or monitoring treatment efficacy. (e.g., Gordon Continuous Performance Test, Test of Variables of Attention, etc. to document effectiveness of ADHD management).
Re-testing done within one year without clear clinical justification.
Baseline neuropsychological testing (including ImPACT) in asymptomatic persons.
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Routine testing upon admission for a behavioral health condition.
Testing of members who are currently engaged in substance misuse, are in withdrawal, or who only recently are abstinent from drugs or alcohol, as testing may be unreliable in such situations.
Documentation Required:
• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity including office notes and reports indicating: a. The referral source, and to whom the results will be conveyed; b. The test(s) proposed for evaluation; c. The amount of time being requested to complete the evaluation; d. The treatment planning issue that testing is expected to clarify; e. A summary of clinical information, including differential diagnosis, prior evaluation performed to date, and therapies or remediation attempted. • Correct coding for the item/service that meets all the coding guidelines.Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.
Neuropsychological testing is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.
State mandates, laws or benchmark supersede this medical guideline.
Guideline Review History:
Implemented 04/04/14, 04/17/15, 07/01/16, 07/01/17, 07/01/18, 10/01/19, 06/01/20, 03/01/21, 03/01/22, 03/01/23, 03/01/24, 09/01/25 Reviewed
03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 06/21/19, 01/31/20, 02/25021, 02/24/22, 02/23/23, 02/28/24, 06/26/25
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Revised 03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 06/21/19, 01/31/20, 02/25/21, 02/24/22 Developed
Medical Guideline Committee Approval 03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 06/21/19, 01/31/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, 06/26/25
Approved by the Medical Director
Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.
Code Description 96132 NEUROPSYCHOLOGICAL TESTING EVALUATION SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING INTEGRATION OF PATIENT DATA, INTERPRETATION OF STANDARDIZED TEST RESULTS AND CLINICAL DATA, CLINICAL DECISION MAKING, TREATMENT PLANNING AND REPORT, AND INTERACTIVE FEEDBACK TO THE PATIENT, FAMILY MEMBER(S) OR CAREGIVER(S), WHEN PERFORMED; FIRST HOUR 96133 NEUROPSYCHOLOGICAL TESTING EVALUATION SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING INTEGRATION OF PATIENT DATA, INTERPRETATION OF STANDARDIZED TEST RESULTS AND CLINICAL DATA, CLINICAL DECISION MAKING, TREATMENT PLANNING AND REPORT, AND INTERACTIVE FEEDBACK TO THE PATIENT, FAMILY MEMBER(S) OR CAREGIVER(S), WHEN PERFORMED; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96136 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, TWO OR MORE TESTS, ANY METHOD; FIRST 30 MINUTES 96137 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, TWO OR MORE TESTS, ANY METHOD; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96138 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY TECHNICIAN, TWO OR MORE TESTS, ANY METHOD; FIRST 30 MINUTES 96139 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY TECHNICIAN, TWO OR MORE TESTS, ANY METHOD; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96146 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION, WITH SINGLE AUTOMATED, STANDARDIZED INSTRUMENT VIA ELECTRONIC PLATFORM, WITH AUTOMATED RESULT ONLY GZ11ZZZ PSYCHOLOGICAL TESTS, PERSONALITY AND BEHAVIORAL GZ12ZZZ PSYCHOLOGICAL TESTS, INTELLECTUAL AND PSYCHOEDUCATIONAL
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GZ13ZZZ PSYCHOLOGICAL TESTS, NEUROPSYCHOLOGICAL Associated Procedure Codes Code Description 96116 NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGMENT, [EG, ACQUIRED KNOWLEDGE, ATTENTION, LANGUAGE, MEMORY, PLANNING AND PROBLEM SOLVING, AND VISUAL SPATIAL ABILITIES]), BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, BOTH FACE-TO-FACE TIME WITH THE PATIENT AND TIME INTERPRETING TEST RESULTS AND PREPARING THE REPORT; FIRST HOUR 96121 NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGEMENT, [EG, ACQUIRED KNOWLEDGE, ATTENTION, LANGUAGE, MEMORY, PLANNING AND PROBLEM SOLVING, AND VISUAL SPATIAL ABILITIES]), BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, BOTH FACE-TO-FACE TIME WITH THE PATIENT AND TIME INTERPRETING TEST RESULTS AND PREPARING THE REPORT; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE- TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT
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Walk through this policy with us
Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.