151 Form

1

Medical Policy Neuropsychological and Psychological Testing Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 151

BCBSA Reference Number: N/A Related Policies
N/A Policyi Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Neuropsychological Testing Neuropsychological testing is considered MEDICALLY NECESSARY when any of the following are met or present: • A complete mental status exam and/or mental health clinical evaluation has been conducted, and • The intent is to assess baseline cognitive functioning to inform clinical intervention or treatment, or • To conduct repeat testing to assess changes in comparison to prior baseline functioning, or • To conduct intraoperative brain mapping, or • To identify candidates who would be appropriate for surgical intervention, or • To clarify/inform differential diagnosis, or • To evaluate the nature of functional deficits related to brain dysfunction, or • When there is lack of treatment response that may be related to cognitive or behavioral dysfunction, OR
• When there is evidence of neurological disease or injury, including but not limited to:
o Traumatic brain injury or history of head injury with altered consciousness or post traumatic amnesia, o Brain tumor, structural malformation of brain or other anatomical brain changes
o Suspected radiation or chemotherapy induced brain injury, o Dementia or mild cognitive impairment suspected or diagnosed, o Epilepsy or seizures, o Neurodegenerative disease, for example, multiple sclerosis, Parkinson’s Disease, Alzheimer’s Disease, Huntington’s Disease
o Neurocognitive disorder associated infectious disease (ie., covid, HAND),
o Anoxic or hypoxic brain injury or postoperative cognitive decline, o History of intracranial surgery, o Confirmed neurotoxin exposure,

2 o Stroke,
o Encephalitis or meningitis,
o Hydrocephalus
o Neonatal or early post neonatal neurodevelopmental condition, for example prematurity, cerebral palsy, neonatal abstinence syndrome, in utero neurotoxin exposure
o Encephalopathy or delirium
o Autism/Autism Spectrum Disorder o Neurodevelopmental conditions/genetic disorders

Neuropsychological testing for Attention Deficit Hyperactivity Disorder (ADHD) may be MEDICALLY NECESSARY for the following: • when routine treatment for ADHD has not improved patient outcomes and there is well documented evidence of treatment failure, or • when psychological/additional testing has been completed or further clinical information is needed to rule out a medical or psychiatric diagnosis.

Neuropsychological testing for the routine diagnosis of ADHD is NOT MEDICALLY NECESSARY.

A typical course of neuropsychological testing evaluation, administration, scoring and interpretation, is completed in 10 hours. Additional hours for neuropsychological testing evaluation services may be requested by submitting clinical documentation.

Psychological Testing Psychological testing may be MEDICALLY NECESSARY to individualize treatment plan when unable to be determined by clinical interview alone, for any of the following: • To make a psychiatric diagnosis, • To assess the presence of a thought disorder, • To assess the level of risk of harm to self or others, • To assess impact of subjective trauma,
• To assess personality factors that may affect functioning,
• To assess individuals with treatment resistant conditions.

A typical course of psychological testing evaluation, administration, scoring and interpretation, is completed in 8 hours. Additional hours for psychological testing evaluation services may be requested by submitting documentation. Testing for more than eight hours should be considered only when there are additional complicating factors, including but are not limited to:
• processing speed deficits,
• language processing deficits,
• need for interpreter services as part of test administration or providing feedback,
• hearing or visual impairment,
• intellectual disability,
• severity of behavioral and personality symptoms that require management during testing or feedback, • other comorbidities,
• diagnostic complexity.

Neuropsychological and Psychological Testing Neuropsychological and/or Psychological testing are considered NOT MEDICALLY NECESSARY for any of the following:
• Testing has been performed in the previous 12 months unless any of the following are present:
• Suspected changes in cognitive or psychological functioning,or
• A new neurological or psychological insult/event
• Determining eligibility for educational or vocational assessment or training (for example: to assess educational achievement or to assess the effectiveness of or need for educational programming), or • baseline assessment of functioning prior to participation in recreational or sports-related activities, or

3 • assessment or monitoring of chronic conditions when there is no suspected change in behavior, mental state, or cognition.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Prior Authorization Requirements for Neuropsychological Testing/Psychological Testing

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required. Psychological and Neuropsychological Assessment Supplemental Form Commercial PPO and Indemnity Prior authorization is not required.

Requesting Prior Authorization Using Authorization Manager
Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly:
• Enter the facility’s NPI or provider ID for where services are being performed.
• Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources
• Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Psychological and Neuropsychological Assessment Supplemental Form using Authorization Manager.

For out of network providers: Requests should still be faxed to 1-888-641-5199. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

NOTE: Computer-based tests which auto-generate a score are not separately reimbursable. Reimbursement for these components is included in the codes for comprehensive testing and evaluation. • Providers who are credentialed to perform comprehensive neuropsychological testing may use computer-based testing as part of the comprehensive evaluation and submit the appropriate neuropsychological evaluation CPT codes.

4 • Providers who are not credentialed to perform comprehensive neuropsychological testing may use computer-based testing. In these situations, reimbursement for computer-based testing used as part of the evaluation is included in the evaluation and management CPT codes. CPT Codes CPT codes: Code Description 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), first hour. 96131 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) each additional hour (List separately in addition to code for primary procedure). 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), 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) each additional hour (List separately in addition to code for primary procedure).
The following codes do not require separate prior authorization but should only be used in conjunction with the codes in the table above: 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) Description Neuropsychological assessments evaluate brain functions and cognition including language, perception, memory, learning, problem solving, adaptation, social emotional functioning, processing, adaptive functioning, and executive functions through objective, valid, and reliable tools (APA, 2019). Neuropsychological assessment includes clinical interview, record review, medical history, behavioral observations, and standardized tests. Neuropsychological assessment may be relevant for individuals with structural brain damage, as well as neuropsychological and neurobehavioral disorders (APA, 2019). Neuropsychological assessment includes the administration, scoring, evaluation, and integration of findings with history and clinical presentation, and the presentation and discussion of the results with the patient, patient’s family, if appropriate, and the referring professional. Findings from neuropsychological evaluation are incorporated into treatment planning.

Psychological assessments evaluate cognitive, behavioral, and emotional functioning, personality, and psychopathology through consideration of the patient’s history, current functioning, psychosocial factors, and interpersonal relationships (APA, 2019). Psychological assessment may evaluate mood, personality, mental state, emotions, thought form and content, and adaptive functioning. Psychological assessment

5 may include clinical interview, record review, medical history, behavioral observations, or standardized and non-standardized tests. Psychological assessment is relevant for a variety of conditions (APA, 2019). Psychological assessment includes the administration, scoring, evaluation, and integration of findings with history and clinical presentation, and the presentation and discussion of the results with the patient, patient’s family, if appropriate, and the referring professional. Findings from psychological evaluation are incorporated into treatment planning. Summary Neuropsychological and psychological evaluations are completed when a clinical assessment or evaluation interview is not sufficient to provide a diagnosis or identify relevant domains of functioning to engage in treatment planning. Neuropsychological and psychological evaluations require the administration of relevant tests, the scoring and interpretation of those tests, the integration of findings with history and clinical presentation. There may be presentation and discussion of the results with the patient, patient’s family, if appropriate, and the referring professional. The immediate goal of the neuropsychological and psychological evaluation may be clarification of diagnosis, determination of functioning across a variety of domains, and development of recommendations for the purpose of treatment planning. Policy History Date Action 3/2024 Policy clarified to specify that a typical course of neuropsychological testing can be completed in 10 hours. 3/1/2024. 1/2024 Reorganized and clarified InterQual criteria into policy #151. Medically necessary criteria reformatted and updated. Policy references updated. 1/2024 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
9/2019 Policy notes regarding provider types eligible for payment for services removed.
8/2019 Not medically necessary indications for neuropsychological testing for educational or vocational assessment disorders clarified.
6/2019
Added not medically necessary criteria to policy.
5/1/2019 Clarified psychological testing unit requirements.
3/22/2019 Prior authorization requirement for Medicare HMO Blue clarified. Effective 1/1/19. 1/2019 New medical policy describing medically necessary and investigational indications for psychological and neuropsychological testing.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. American Psychiatric Association. Practice guideline for psychiatric evaluation of adults, third edition. In: American Psychiatric Association practice guidelines for the treatment of psychiatric disorders. Washington: American Psychiatric Association; 2016: 1-64.
2. Baldwin and Farias. Neuropsychological assessment in the diagnosis of Alzheimer’s disease. Curr Protoc Neurosci 2009. Chapter 10: Unit 13. (V)
3. Dalla Barba et al. Neuropsychological examination in dementia. Handb Clin Neurol 2008. 89:15-33. (v)
4. Elshorst et al. Postoperative memory prediction in left temporal lobe epilepsy: the Wada test is of no added value to preoperative neuropsychological assessment and MRI. Epilepsy Behav 2009.
   16(2): 335-340. (III)
5. Johnson. The Neuropsychology of multiple sclerosis. Dis Mon 2007. 53(3):172-176. (V)

6

6. Russell et al. The fundamental psychometric status of neuropsychological batteries. Arch Clin Neuropsychol 2005. 20(6):785-794. (V)
7. Weintraub et al. The Alzheimer’s of Disease Centers’ Uniform Data Set (UDS): the neuropsychological test battery. Alzheimer Dis Assoc Disord 2009. 23(2): 91-101. (V)
8. Banks. The role of neuropsychological testing and evaluation: when to refer. Adolesc Med 2002. 13(3):643-662. (V)
9. Dodrill. Neuropsychological effects of seizures. Epilepsy Behav 2004. 5(Suppl 1):S21-24. (I)
10. Heilbronner et al. Official position of the American Academy of Clinical Neuropsychological on serial neuropsychological assessments: the utility and challenges of repeat test administrations in clinical and forensic contexts. Clin Neuropsychol 2010. 24(8):1267-78. (V)
11. Kane. The role of pediatric neuropsychological assessment in primary care practice. Dis Mon 2007.
12. Reitan and Wolfson. Serial testing of older children as basis for recommending comprehensive neuropsychological evaluation. Appl Neuropsycho 2008. 15(1):11-20. (III)
13. Russell et al. The fundamental psychometric status of neuropsychology batteries Arch Clin Neuropsychol 2005. 20(6):785-794. (V)
14. Davidson et al. Evaluation of techniques for assessing neurobehavioral development in children Neurotoxicology 200.21(6):957-972. (V)
15. Korkman et al. Neurocognitive test profiles of extremely low birth weight five-year-old-children differ according to neuromotor status. Dav Neuropsychol 2008. 33(5):637-55. (III)
16. Nelson and Fisher. Neuropsychological evaluation of the child with epilepsy. Dis Mon 2007. 53(3):162-168. (V)
17. Anastasi, A., 1988 Psychological Testing, 6th ed. N.Y. Macmillan.
18. Butler, R.W.et al p.19 Psychological Assessment of Adults and Children in Kaplan, H.I. and Sadock, B.J. eds., Comprehensive Textbook of Psychiatry, vol. 1 15th edition.
19. Kleban, M., Abright, R. A. Specific Learning Disabilities and Difficulties in Children and Adolescents: Psychological Assessment and Evaluation. February 2003. 54(2). P. 262. https://doi.org/10.1176/appi.ps.54.2.262
20. Recent Advances in Diagnostic Psychological Testing: A Critical Summary. JAMA. 1951;145(2):125. doi:10.1001/jama.1951.02920200065039 https://jamanetwork.com/journals/jama/article- abstract/309055?resultClick=1&redirect=true
21. Diagnostic Psychological Testing: The Theory, Statistical Evaluation, and Diagnostic Application of a Battery of Tests. Volume II. JAMA. 1947,133(1):71. doi:10.1001/jama.1947.02880010073023. https://jamanetwork.com/journals/jama/article-abstract/290803?redirect=true
22. Halperin, J., McKay, K. Psychological Testing for Child and Adolescent Psychiatrists: A Review of the Past 10 Years. June 1998. 37(6). 575-584. DOI: https://doi.org/10.1097/00004583-199806000-00007
23. Rootes, M. The Interpretation of Psychological Tests. December 1968. Archives of General Psychiatry. 1968;19(6):759-760. doi:10.1001/archpsyc.1968.01740120119017 https://jamanetwork.com/journals/jamapsychiatry/article-abstract/489851?redirect=true
24. Piotrowski, C., Keller, J. W. (1989). Psychological testing in outpatient mental health facilities: A national study. Professional Psychology: Research and Practice, 20(6), 423-425. http://dx.doi.org/10.1037/0735-7028.20.6.423
25. Meyer, J.G., Finn, S., Eyde, S. Psychological testing and psychological assessment: A review of evidence and issues. American Psychologist, Vol 56(2), Feb 2001, 128-165.
26. Hunsley,J., Meyer, J.G. The Incremental Validity of Psychological Testing and Assessment: Conceptual, Methodological, and Statistical Issues. Psychological Assessment, Vol 15(4), Dec 2003, 446-455.
27. Fletcher, J., Miciak, J. Comprehensive Cognitive Assessments are not Necessary for the Identification and Treatment of Learning Disabilities. Archives of Clinical Neuropsychology. Feb 2017. 32(1): 2-7.
28. Fletcher, J., Francis, D., Morris, R., et al. Evidence-based assessment of learning disabilities in children and adolescents. Journal of Clinical Child Adolescent Psychology. September 2005. 34(3). 506-522.
29. Meyer, G., Finn, S., Eyde, L., et al. Psychological testing and psychological assessment: A review of evidence and issues. American Psychologist. 2001. 56(2), 128-165.
30. Cortiella, C., Horowitz, S.H. The State of Learning Disabilites; Facts, Trends and Emerging Issues. New York: National Center for Learning Disabilities, 2014.

7

A full set of references is available upon request.

Endnotes

i Based on expert opinion