This document addresses the use of neuropsychological testing, also known as psychometric testing, which refers to a quantitative, comprehensive evaluation of cognitive, motor and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders. This testing may be used to augment a comprehensive medical history and physical examination, as well as a neurological investigation of certain conditions.
Note: This document does not address testing for psychological/behavioral mental health-related evaluations.
Please see the following documents for information related to testing for behavioral health-related conditions:
Neuropsychological testing is considered medically necessary for any of the following indications:
- When there are only mild or questionable deficits on standard mental status testing, and more precise evaluation is needed to establish the presence of abnormalities or distinguish them from changes that may occur with normal aging or the expected progression of other disease processes; or
- When there is a need to quantify the deficits, particularly when the information will be useful in determining a prognosis; or
- When there is a need to characterize the strengths and weaknesses of an individual, as a guide to treatment or rehabilitation planning; or
- When neuropsychological data can provide a more comprehensive profile of function that, when combined with clinical, laboratory, and imaging data, may assist in determining a diagnosis; or
- When the individual is being considered for epilepsy surgery.
Note: Repeat testing to track the status of an illness or recovery progress is generally not warranted.
Clinical conditions which may require the use of neuropsychological testing may include, but are not limited to:
- Traumatic brain injury;
- Cerebrovascular disease (in the recovery/rehabilitation phase following significant clinical recovery when there is still evidence of cognitive impairment or as a guide to rehab and treatment planning);
- Parkinson's disease;
- Human immunodeficiency virus encephalopathy;
- Multiple sclerosis;
- Epilepsy (as part of presurgical treatment planning);
- Neurotoxic exposure;
- Hypoxic brain injury;
- Chronic pain (when used to assess personality and mood or to perform a cognitive assessment if symptoms indicate intellectual disturbances after discontinuation of pain-relieving or psychotropic medications);
- Neurologic disease (when used as an adjunctive personality assessment for identified or suspected brain disorders, such as brain tumors, hypoxic brain injury).
Note: Testing requests for medical indications not listed above and for retesting are reviewed on an individual case-by-case basis to determine medical necessity.
Not Medically Necessary:
Neuropsychological testing is considered not medically necessary when the criteria outlined above are not met, including, but not limited to:
- When similar neuropsychological testing has been performed in the last 12 months (subject to individual case consideration for medical necessity);
- When there is no clinical diagnosis or symptoms/behaviors suggestive of the need for this testing;
- When test results will not directly contribute to or impact the treatment plan;
- For evaluation of suspected Attention Deficit Disorder (AD) with or without Hyperactivity Disorder (AD/HD);
- For other non-medical uses of this testing, (for example, educational/vocational purposes; as a routine screening test of cognitive function; forensic applications; to evaluate malingering).
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|96116||Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report|
|96118||Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report|
|96119||Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face|
|96120||Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report|
| || |
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
| ||All diagnoses|
| || |
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
| ||All diagnoses|
| || |
The selection of specific tests and the timing of administration should be determined by the provider. Standardized neuropsychological tests rely on published national normative data and include established standardized or scaled scoring ranges. The duration of testing will also vary based on the condition, and, in many cases, more than three (3) hours of testing would not be needed. Test choice should be customized to the individual's deficits and will be based on multiple factors including, but not limited to:
- Severity of the individual's deficits;
- Nature of the brain disorder, (for example, stroke, degenerative, trauma);
- Characteristics of the clinical syndrome, (for example, whether aphasia is present);
- Age of the individual;
- Associated physical limitations;
- Neuropsychiatric disorders, (for example, depression, anxiety);
- Effects of medications;
- History of developmental disabilities;
- History of substance abuse.
The value of neuropsychological testing is dependent upon the cooperation and effort of the individual being tested. Testing should be considered only after appropriate assessment and optimal treatment of any factor that would affect cooperation and effort. Examples of these include: medication effects, alcohol or other substance abuse, and mood disorders.
Neuropsychological Testing assessments by themselves are insufficient, as a basis for decisions regarding medical therapy and are not intended to provide recommendations for specific diagnostic and pharmacologic interventions. Neuropsychological testing results reflect functional capacity and are not diagnostic of a specific etiology or indicative of a precise localization of a neurologic disease. The purpose of testing must be to help establish the diagnosis and to develop a treatment plan for a mental disorder when the diagnosis or treatment plan cannot be determined based on available information from one or more comprehensive medical or behavioral health evaluations with the affected individual and appropriate ancillary information sources (for example, family members, health care providers, school records).
Regarding Attention Deficit Disorder (AD) with or without Hyperactivity Disorder (AD/HD), a diagnosis is typically confirmed with the use of full clinical and psychosocial assessments, individual clinical/psychosocial history, results of standardized rating scales and observational data from family members, teachers, etc. According to the updated Clinical Guideline 72 from the National Institute for Health and Clinical Excellence (NICE) on Attention Deficit Hyperactivity Disorder Diagnosis and Management of ADHD in Children, Young People and Adults:
ADHD is a heterogeneous behavioral syndrome characterized by the core symptoms of hyperactivity, impulsivity and inattention. While these symptoms tend to cluster together, some people are predominantly hyperactive and impulsive, while others are principally inattentive. Two main diagnostic criteria are in current use – the International Classification of Mental and Behavioral Disorders, 10th revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).
This NICE guideline provides the following recommendations for testing in the setting of suspected AD/HD:
Symptoms of hyperactivity/impulsivity and/or inattention should:
- Meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder); and
- Be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings; and
- Be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.
- As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people, there should also be an assessment of their parents' or carers' mental health (NICE, 2013).
Current published evidence and specialty society recommendations do not support the widespread use of neuropsychological testing in the diagnostic evaluation of suspected AD/HD in children or adults. Further research is needed to better define the role of neuropsychological testing in AD/HD (Haavik, 2010; Kovner, 1998; Pineda, 2007; Pliszka, 2007; Weiss, 2003).
In 2010, the American Academy of Pediatrics (AAP) published a clinical report regarding sport-related concussion in children and adolescents. This report notes that neuropsychological testing can be helpful to provide objective data to athletes and their families after a concussion (which is also referred to as mild traumatic brain injury [mTBI]). The report states, "Neuropsychological testing is one tool in the complete management of a sport-related concussion and alone does not make a diagnosis or determine when return to play is appropriate." The report also comments that further research is needed to determine the optimum time and protocol for testing (Halstead, 2010).
Neuropsychological testing is to be performed by clinicians, (for example, physicians, psychologists) appropriately trained to perform and interpret test results, when this type of testing evaluation falls within their scope of professional practice.
Neuropsychological testing is typically a comprehensive battery of tests to assess multiple cognitive domains, such as intelligence, learning ability, motor function, memory, reasoning, receptive and expressive language skills, etc. One example of such a test is the Minnesota Multiphasic Personality Inventory (MMPI), which is commonly used for both neuropsychological and psychological testing.
Peer Reviewed Publications:
- Adler LA, Newcorn JH. The impact, identification, and management of attention-deficit/hyperactivity disorder in adults. Introduction. CNS Spectr. 2007; 12(12 Suppl 23):1-2.
- Banks ME. The role of neuropsychological testing and evaluation: when to refer. Adolesc Med. 2002; 13(3):643-662.
- Bidwell LC, Willcutt EG, Defries JC, Pennington BF. Testing for neuropsychological endophenotypes in siblings discordant for attention-deficit/hyperactivity disorder. Biol Psychiatry. 2007; 62(9):991-998.
- Binder LM, Campbell KA. Medically unexplained symptoms and neuropsychological assessment. J Clin Exp Neuropsychol. 2004; 26(3):369-392.
- Boake C, Millis SR, High WM, et al. Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury. Arch Phys Med Rehabil. 2001; 82(6):761-768.
- Claypoole KH, Noonan C, Mahurin RK, et al. A twin study of cognitive function in chronic fatigue syndrome: The effects of sudden illness onset. Neuropsychology. 2007; 21(4):507-513.
- Dige N, Wik G. Adult attention deficit hyperactivity disorder identified by neuropsychological testing. Int J Neurosci. 2005; 115(2):169-183.
- Feifel D. Attention-deficit hyperactivity disorder in adults. Postgrad Med. 1996; 100(3):207-211, 215-218.
- Goldberg E, Bougakov D. Neuropsychologic assessment of frontal lobe dysfunction. Psychiatr Clin N Am. 2005; 28(3):567-580.
- Goldstein MA, Silverman ME. Neuropsychiatric assessment. Psychiatr Clin North Am. 2005; 28(3):507-547.
- Haavik J, Halmøy A, Lundervold AJ, Fasmer OB. Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother. 2010; 10(10):1569-1580.
- Korkman M, Peltomaa K. A pattern of test findings predicting attention problems at school. J Abnorm Child Psychol. 1991; 19(4):451-467.
- Kovner R, Budman C, Frank Y, et al. Neuropsychological testing in adult attention deficit hyperactivity disorder: a pilot study. Int J Neurosci. 1998; 96(3-4):225-235.
- Palumbo D, Lynch PA. Psychological testing in adolescent medicine. Adolesc Med Clin. 2006; 17(1):147-164.
- Pineda DA, Puerta IC, Aguirre DC, et al. The role of neuropsychologic tests in the diagnosis of attention deficit hyperactivity disorder. Pediatr Neurol. 2007; 36(6):373-381.
- Post RE, Kurlansik SL. Diagnosis and management of adult attention-deficit/hyperactivity disorder. Am Fam Physician. 2012; 85(9):890-896.
- Sachdev PS, Brodaty H, Valenzuela MJ, et al. The neuropsychological profile of vascular cognitive impairment in stroke and TIA patients. Neurology. 2004; 62(6):912-919.
- Trollor JN. Attention deficit hyperactivity disorder in adults: conceptual and clinical issues. Med J Aust. 1999; 171(8):421-425.
- Tucha L, Tucha O, Laufkötter R, et al. Neuropsychological assessment of attention in adults with different subtypes of attention-deficit/hyperactivity disorder. J Neural Transm. 2008;115(2):269-278.
- Weiss M, Murray C. Assessment and management of attention-deficit hyperactivity disorder in adults. CMAJ. 2003; 168(6):715-722.
- Wild K, Howieson D, Webbe F, et al. Status of computerized cognitive testing in aging: A systematic review. Alzheimers Dement. 2008; 4(6):428-437.
Government Agency, Medical Society, and Other Authoritative Publications:
- American Psychiatric Association. Policies and Clinical Resources. 2014. Available at: http://www.psychiatry.org/practice/professional-interests/psychosomatic-medicine/practice/policies-and-clinical-resources. Accessed on July 25, 2014.
- American Academy of Pediatrics (AAP). Clinical Practice Guideline: AD/HD. Diagnose, Evaluation, and Treatment of ADHD in Children and Adolescents. Pediatrics. 2011; 128(5):1007-1022. Available at: http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654/suppl/DC1. Accessed on July 25, 2014.
- American Psychiatric Association. Practice guideline for the Psychiatric Evaluation of Adults. Second Edition. June 2006. Available at: http://www.psychiatryonline.com/pracGuide/pracGuideTopic_1.aspx. Accessed on July 25, 2014.
- American Psychological Association. Guidelines for psychological practice with older adults. May-June, 2004. Available at: http://www.apa.org/practice/guidelines/older-adults.pdf. Accessed on July 25, 2014.
- American Academy of Child and Adolescent Psychiatry (AACAP). ADHD - A Guide for Families. Attention deficit/hyperactivity. Copyright ©2010 - American Academy of Child Adolescent Psychiatry. Available at: http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/ADHD_Resource_Center/ADHD_A_Guide_for_Families/What_
is_ADHD.aspx. Accessed on July 25, 2014.
- American Psychological Association. Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia. Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association. Updated January 2012. Available at: http://www.apa.org/pi/aging/resources/dementia-guidelines.pdf. Accessed on July 25, 2014.
- Centers for Medicaid & Medicare Services (CMS). Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): Psychological and Neuropsychological Testing (L31990). Effective February 1, 2014. Available at: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31990&ContrId
Corporation+(08102%2c+MAC+-+Part+B)&s=20&DocType=Active&bc=AggAAAIAAAAAAA%3d%3d&#. Accessed on July 25, 2014.
- Children's Oncology Group, National Cancer Institute (NCI). Neuropsychological and Behavioral Testing in Young Patients with Cancer. Cochrane Database Syst Rev. October 14, 2008; NCT00772200. Last updated February 24, 2014. Available at: http://www.clinicaltrials.gov/ct2/show/NCT00772200?term=neuropsychological&rank=5. Accessed on July 25, 2014.
- Cushman JG, Agarwal N, Fabian TC, et al. Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group. Practice management guidelines for the management of mild traumatic brain injury. Winston-Salem, NC. 2000. Available at: http://www.east.org/Content/documents/practicemanagementguidelines/brain-mild-traumatic-injury-management.pdf. Accessed on July 25, 2014.
- Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: Screening and Diagnosis of Autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000; 55(4):468-479.
- Gallagher R, Blader J. The diagnosis and neuropsychological assessment of adult attention deficit/hyperactivity disorder. Scientific study and practical guidelines. Ann N Y Acad Sci. 2001; 931:148-171.
- Halstead ME, Walter KD, and The Council on Sports Medicine and Fitness. American Academy of Pediatrics (AAP). Sport-Related Concussion in Children and Adolescents. Pediatrics. 2010; 126:597-615.
- Knopman DS, DeKosky ST, Cummings JL, et al. American Academy of Neurology (AAN). Practice parameter: Diagnosis of Dementia (An Evidence-based Review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001; 56:1143-1153. Available at: http://www.neurology.org/content/56/9/1143.full.pdf. Accessed on July 25, 2014.
- National Institute for Health and Clinical Excellence (NICE). NICE Clinical Guideline 72. Developed by the National Collaborating Centre for Mental Health. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults. September 2008; modified July 2014. Available at: http://pathways.nice.org.uk/pathways/attention-deficit-hyperactivity-disorder?fno=1. Accessed on July 25, 2014.
- National Institute for Health and Clinical Excellence (NICE). NICE Clinical Guideline 137. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. January 2012. Available at: http://publications.nice.org.uk/the-epilepsies-the-diagnosis-and-management-of-the-epilepsies-in-adults-and-children-in-primary-and-cg137. Accessed on July 25, 2014.
- National Institute for Health and Clinical Excellence (NICE). NICE Clinical Guideline 42. Dementia: Supporting people with dementia and their carers in health and social care. November 2006; last modified October 2012. Available at: http://guidance.nice.org.uk/CG42. Accessed on July 25, 2014.
- Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: Early detection of dementia; mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001; 56(9):1133-1142.
- Pliszka S, AACAP Work Group on Quality Issues. American Academy of Child and Adolescent Psychiatry (AACAP). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007; 46(7):894-921.
- Randolph C, Hilsabeck R, Kato A, et al. International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN). Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int. 2009; 29(5):629-635.
- Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med. 2005; 352(2):165-173.
- U.S. Preventive Services Task Force (USPSTF). Recommendation for Screening for Cognitive Impairment in Older Adults. March 2014. Available at: http://www.uspreventiveservicestaskforce.org/uspstopics.htm. Accessed on July 25, 2014.
- Volkmar F, Cook EH Jr, Pomeroy J, et al. Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues. J Am Acad Child Adolesc Psychiatry. 1999; 38(12 Suppl):32S-54S.
|Websites for Additional Information|
- National Alliance for Mental Illness (NAMI). Attention-deficit/hyperactivity disorder (ADHD). May, 2003. Available at: http://www.nami.org/Content/Microsites138/NAMI_Fort_Wayne_Indiana/Home128/Resources_for_Educators/ADHD_facts.pdf. Accessed on July 25, 2014.
- National Institute of Mental Health (NIMH). Attention deficit hyperactivity disorder (ADHD). Last reviewed: October 4, 2010. Available at: http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml. Accessed on July 25, 2014.
|Reviewed||08/14/2014||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Reviewed||08/08/2014||Behavioral Health Subcommittee review. References and Websites sections were updated.|
|Reviewed||08/08/2013||MPTAC review. No further revisions to criteria. The Discussion section was updated.|
|Reviewed||07/26/2013||Behavioral Health Subcommittee review.|
|Revised||05/09/2013||MPTAC review. Evaluation of AD/HD has been added to the not medically necessary indications for testing. Discussion section and References were updated.|
|Reviewed||08/09/2012||MPTAC review. No change to criteria. Discussion section and References were updated.|
|Reviewed||08/18/2011||MPTAC review. No change to criteria. Coding and References were updated.|
|Reviewed||08/19/2010||MPTAC review. No change to criteria. References were updated.|
|Reviewed||08/27/2009||MPTAC review. No change to criteria. References were updated.|
|Reviewed||08/28/2008||MPTAC review. No change to criteria. References were updated.|
|Reviewed||08/23/2007||MPTAC review. No change to criteria. References were updated. Coding updated; removed CPT 96115, 96117 deleted 12/31/2005.|
|Reviewed||09/14/2006||MPTAC review. No change to guideline criteria. References were updated.|
| ||01/01/2006||Updated coding section with 01/01/2006 CPT/HCPCS changes|
| ||11/22/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Anthem BCBS NH|
|Local Region UM Document||Neuropsychological Testing|
|Anthem BCBS West Region|
|Local Region UM Document UMR.002||Neuropsychological Testing|
|WellPoint Health Networks, Inc.|
|Clinical Guideline ||Neuropsychological Testing|