Psychologic Evaluation for Medical Procedures Form

MEDICAL COVERAGE POLICY SERVICE: Psychologic Evaluation for Medical Procedures Policy Number: 137 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 1 of 5 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Psychological Evaluation for Medical and Surgical Procedures PRIOR AUTHORIZATION: Required. POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for coverage details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination) L35101 Psychiatric Codes. If there are no applicable NCD or LCD criteria, use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider psychological evaluation and testing medically necessary prior to certain medical and surgical procedures.

1. Members should meet the medical necessity criteria for the planned procedure PRIOR TO the psychological evaluation.
2. Psychological and neuropsychological testing, when authorized, may only be conducted by a psychologist who is both experienced and trained in psychological and neuropsychological assessment and is currently licensed and authorized to practice by the state of Texas. This policy is not intended to address mental health evaluations for mental health issues, only for the purpose of evaluating a patient for a medical or surgical procedure, excluding surgery for epilepsy or Parkinson’s Disease. For this purpose, BSWHP may consider up to five hours total of psychological evaluation and testing for a specific medical procedure as medically necessary. This typically consists of one hour of psychiatric diagnostic interview (CPT 90791) and up to four hours of testing/scoring (see code list). Additional hours beyond five may be authorized upon documented clinical justification for complex cases.

MEDICAL COVERAGE POLICY SERVICE: Psychologic Evaluation for Medical Procedures Policy Number: 137 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 2 of 5 Testing and hours will be reviewed to ensure:

1. The number of hours or units requested for testing does not exceed the reasonable time necessary to address the clinical questions with the identified measures; and
2. The testing techniques are validated for the proposed diagnostic question or treatment plan; and
3. The testing techniques do not represent redundant measurements of the same cognitive, behavioral or emotional domain; and
4. The testing techniques are both validated for the age and population of the member; and they are the most updated version of the instrument; and NOTE: Testing by technician, or via computer/electronic format (CPT codes 96138 and 96139, psychological testing administered by a technician, as well as the CPT code 96146 which is psychological testing administered by computer/electronic format) are not covered as discussed above. Presurgical psychological evaluation requires integration of clinical judgment with test data, which necessitates direct administration and interpretation by a qualified professional. Brief screening measures such as the Folstein Mini-Mental Status Exam or use of other mental status exams in isolation should not be reported separately as psychological or neuropsychological testing, since they are typically part of a more general clinical exam or interview. BACKGROUND:
   Patients must have the ability to understand and comply with the requirements of medical and surgical procedures. Certain procedures require more patient understanding, insight, and participation. Psychological clearance is sometimes sought prior to such procedures. Examples include (but are not limited to) placement of spinal cord stimulators, organ transplants and bariatric surgery. Current clinical practice guidelines from multiple specialty societies support presurgical psychological evaluation for these procedures. The AACE/TOS/ASMBS 2019 guidelines recommend behavioral health evaluation for all bariatric surgery candidates. Evidence-based consensus guidelines for spinal cord stimulation (Shanthanna et al., 2023) recommend psychological assessment to identify factors that may predict poor outcomes. KDIGO (2020) and AASLD/AST (2025) guidelines recommend psychosocial evaluation as part of transplant candidacy assessment. The evaluation serves to identify modifiable risk factors, optimize patient preparation, and ensure informed consent capacity — not to serve as a gatekeeping barrier to care. MANDATES: None

MEDICAL COVERAGE POLICY SERVICE: Psychologic Evaluation for Medical Procedures Policy Number: 137 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 3 of 5 CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes 90791 Psychiatric diagnostic evaluation 96130 Psychological 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 96131 ... each additional hour (List separately in addition to code for primary procedure) 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) 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 ... each additional 30 minutes (List separately in addition to code for primary procedure) CPT codes NOT covered 96138 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes 96139 ... 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 ICD10 codes E66.01 - Morbid obesity E66.02 - Morbid obesity G89.2(xx), G90.9 - Chronic pain, CRPS G10, G14 - Systemic atrophies CNS related G20, G26 - EPS and movement disorders M96.1 - Post laminectomy syndrome Z94.0 – Kidney transplant status Z94.1 – Heart transplant status Z94.2 – Lung transplant status Z94.4 – Liver transplant status Z76.82 – Awaiting organ transplant status G89.4 – Chronic pain syndrome F45.42 – Pain disorder with related psychological factors G24.x – Dystonia (DBS candidates) POLICY HISTORY: Status Date Action New 08/01/2010 New policy Reviewed 12/08/2011 Reviewed.

MEDICAL COVERAGE POLICY SERVICE: Psychologic Evaluation for Medical Procedures Policy Number: 137 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 4 of 5 Reviewed 03/16/2012 Reviewed. Reviewed 03/07/2013 Reviewed – no significant changes. Reviewed 02/20/2014 Reviewed. ICD10 codes added. Reviewed 03/05/2015 No changes Reviewed 03/17/2016 Reviewed. Reviewed 03/07/2017 Some updates and corrections to criteria Reviewed 02/06/2018 No changes Reviewed 06/27/2019 Updated codes Reviewed 07/30/2020 Added language to include all LOBs Reviewed 07/22/2021 Added language regarding non-coverage of testing by technician or computer. Update 08/26/2021 Updated code 90801 (retired code) to 90791 Reviewed 09/22/2022 No changes Updated 09/22/2023 Minor edit to reflect previous CPT code change, formatting changes, added hyperlinks to NCD and TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes. Reviewed 03/11/2024 Corrected the “For Medicaid Plans” section to utilize this Medical Policy if TMPPM does not have medical necessity guidance. Reviewed 05/13/2024 Added reference Reviewed 05/12/2025 No changes Updated 08/11/2025 Removed, “Medicare NCD or LCD specific InterQual criteria may be used when available.” Reviewed 05/28/2026 Added flexibility for additional hours with clinical justification, clinical rationale for technician/computer non-coverage, expanded Background with current guidelines, added ICD-10 codes for transplant/chronic pain/dystonia, Updated References REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence surrounding psychological evaluation for medical and surgical procedures and may modify this policy at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures — 2019 update. Endocr Pract. 2019;25(12):1346–

MEDICAL COVERAGE POLICY SERVICE: Psychologic Evaluation for Medical Procedures Policy Number: 137 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 5 of 5

1360. Shanthanna H, Eldabe S, Provenzano DA, et al. Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain. Reg Anesth Pain Med. 2023;48(6):273–
1362. KDIGO. Clinical practice guideline on the evaluation and management of candidates for kidney transplantation. Transplantation. 2020;104(4S1 Suppl 1):S72–S104.
1363. Dove L, Chadha RM, Lai JC, et al. AASLD AST practice guideline on adult liver transplantation: candidate evaluation. Hepatology. 2025.
1364. Marek RJ, Heinberg LJ. Should presurgical psychological evaluations still be a mandated requirement for metabolic and bariatric surgery? Surg Obes Relat Dis. 2024;20(12):1360–1369.
1365. Sockalingam S, Hawa R, Micula-Gondek W, et al. Resource document on bariatric surgery and psychiatric care. American Psychiatric Association. 2016.
1366. Fisher K, Furtado-Pessoa-de-Mendonca L, Kaushal S, et al. A proposed psychologic clearance algorithm for spinal cord stimulation implantation supported by a scoping review. Neuromodulation. 2024;27(8):1294–1304. Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.
      RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.