Neuropsychological testing and assessment provide information about diagnosis, prognosis, and treatment of disorders that are known to impact central nervous system (CNS) functioning, and predict functional abilities across a variety of disorders.

Neuropsychological testing and assessment are a covered benefit when specific cognitive impairments are suspected or have been identified, and when the testing is performed to address questions that have not been able to be answered after a medical or behavioral health evaluation.

Clinical Guideline Coverage Criteria

The Plan requires the use of the following InterQual Subsets or SmartSheets to obtain prior authorization for Neuropsychological Testing:

1. Neuropsychological and Developmental Testing

Limitations

The Plan considers Neuropsychological Testing and Assessment as not reasonable or medically necessary for any of the following:

1. The testing is primarily for the purpose of qualifying for services that are covered under applicable state or federal special education laws.
2. The testing is being conducted primarily for educational (including learning disabilities), vocational or legal purposes.
3. The testing is being conducted primarily to make or confirm a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) that can reasonably be made or confirmed via conventional interviewing, history, and collateral contact/data collection.
4. The testing is a request to repeat previous or similar testing, and there has not been a significant change in functioning or there isn't a clear reason to expect that the testing would yield new information or further impact the clinical management of the patient.
5. Known medication side effects or substance use explain the symptoms and/or suggest that test results would be invalid or inaccurate. Current abstinence from substances is required.
6. The patient is actively psychotic to a degree that testing is unlikely to be successful or results are likely to be invalid.
7. Lab work or other clinical studies of potentially acute and/or reversible conditions that could explain the symptoms have not been performed.
8. The testing is being used as a screening tool or as the primary or initial approach to evaluation.
9. The time requested for the testing exceeds the time that has been indicated by the publisher or in the scientific literature (plus ancillary time covered by the procedure code, if any), and the clinical information submitted does not support a need for the requested amount of time. In such circumstances the Plan may approve less time than requested

Codes