Neuropsychological and Psychological Testing

Number: 0158

Policy

Aetna considers neuropsychological testing (NPT) medically necessary when provided to aid in the assessment of cognitive impairment due to medical or psychiatric conditions, when all of the following criteria are met:

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 submitted are both validated for the age and population of the member; and they are the most updated version of the instrument; and
5. The instruments selected have the empirically substantiated reliability, validity, standardized administration and clinically relevant normative data to assess the diagnostic question or treatment planning goals. 

Examples of medically necessary indications for NPT testing include, but are not limited to:

• Assessment of neurocognitive abilities following traumatic brain injury, stroke, or neurosurgery or relating to a medical diagnosis, such as epilepsy, hydrocephalus or AIDS.
• Assessment of neurocognitive functions to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders.
• Differential diagnosis between psychogenic and neurogenic syndromes.
• Monitoring of the progression of cognitive impairment secondary to neurological disorders.

Aetna considers neuropsychological (NPT) or psychological testing (PT) medically necessary when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation if:

• Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility; or
• Testing is needed to develop treatment recommendations after the member has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic; and

AND all of the following criteria are met:

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
5. The instruments selected have the empirically substantiated reliability, validity, standardized administration and clinically relevant normative data to assess the diagnostic question or treatment planning goals. 

NPT and PT generally are not considered medically necessary for pre-surgical clearance.  An evaluation by a psychologist or psychiatrist is sometimes required (for an example, see CPB 0157 - Obesity Surgery).

NPT or PT is rarely considered medically necessary for uncomplicated cases of attention deficit disorder with/without hyperactivity (ADHD).  However, referral to an outpatient mental health provider or outpatient chemical dependency rehabilitation may be considered medically necessary for the evaluation and comprehensive bio-psychosocial treatment for these disorders in collaboration with primary care physicians and other specialists.  NPT may be considered medically necessary for neurologically complicated cases of ADHD, (e.g., post head trauma, seizures).

NPT or PT beyond standardized parent interviews and direct, structured behavioral observation is rarely considered medically necessary for the diagnosis of pervasive developmental disorders (see CPB 0648 - Autism Spectrum Disorders).

NPT is considered not medically necessary for diagnosis and management of persons with chronic fatigue syndrome, and evaluation of migraineurs.  (Note: PT may be medically necessary to differentiate chronic fatigue syndrome from psychiatric diagnoses when criteria for PT are met.)

NPT or PT is considered not medically necessary if the member is actively abusing substances, is having acute withdrawal symptoms, or has recently entered recovery, because test results may be invalid.

Reimbursement Notes:

• NPT requested for the evaluation of a mental health diagnosis (e.g., serious psychiatric illness, alcohol and/or drug abuse) is considered for coverage through the mental health benefit. If NPT or PT is requested for evaluation of a medical diagnosis (e.g., traumatic brain injury, stroke, differentiation of brain damage from a depressive disorder, epilepsy, hydrocephalus, Alzheimer's disease, Parkinson disease, multiple sclerosis, or AIDS), it is considered for coverage under the medical benefit.
• NPT may also be used in evaluating the impact of chronic solvent or heavy metal exposure particularly in the occupational or environmental medicine realm.  In these cases, NPT would not be covered under Aetna's medical or mental health benefits, but may be covered by the worker's compensation carrier.
• NPT or PT for educational reasons is not covered.  This testing is usually provided by school systems under applicable state and federal rules.  Most benefit plans exclude coverage of educational testing.  Please check benefit plan descriptions.  In addition, NPT or PT performed for educational reasons is not considered treatment of disease.
• NPT or PT for employment, disability qualification, or legal/court-related purposes is not covered as it is not considered treatment of disease.

Background

Psychological tests assess a range of mental abilities and attributes, including achievement and ability, personality, and neurological functioning.  Psychological testing, including neuropsychological assessment, utilizes a set of standardized tests, whose validity and reliability have been established empirically.  They allow for an assessment of a patient's cognitive and behavioral functioning and an analysis of changes related to mental or physical disease, injury, or abnormal development of the brain.  Research has shown that the scores from these tests are reproducible and can be compared to those of normal persons of similar age, sex and demographic background to yield valid conclusions.

Psychological and neuropsychological tests provide a standardized means of sampling behavior, an objective method for evaluating responses, and a tool for comparing the functioning of an individual with peers.  Standardized tests are administered under uniform conditions, scored objectively -- the procedures for scoring the test are specified in detail -- and designed to measure relative performance.  Test results usually are interpreted with reference to a comparable group of people, the standardization, or normative sample.

Psychological testing requires a clinically-trained examiner.  All psychological tests should be administered, scored, and interpreted by a qualified professional, such as a licensed psychologist or psychiatrist, with expertise in the appropriate area.

Psychological tests are only one element of a psychological assessment.  They should never be used as the sole basis for a diagnosis.  A detailed clinical interview, including a complete history of the test subject and a review of psychological, medical, educational, and other relevant records is required to lay the groundwork for interpreting the results of any psychological measurement.

Psychological tests are used to address a variety of questions about people’s functioning, diagnostic classification, co-morbidity, and choice of treatment approach.  For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual’s interpersonal functioning.  The results of these tests determine an individual's personality strengths and weaknesses, and may identify certain disturbances in personality, or psychopathology.  One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots.  The subject's responses can provide insight into his or her thought processes and personality traits.

Neuropsychological testing is a subclassification of psychological testing anda well-established method for evaluating patients who demonstrate cognitive or behavioral abnormalities.  Neuropsychological testing is used when a differentiation between organic versus functional disorders is needed to direct proper therapy (e.g., occupational, physical, or speech and language therapy), predict neuropsychological recovery, or monitor progress.  Neuropsychological tests include: Halsted-Reitan neuropsychological battery or its components; Luria-Nebraska; Wechsler Adult Intelligence Scale (WAIS); Wechsler Intelligence Scales for Children - Revised (WISC-R); Wechsler Memory Scale; and the Reitan-Indiana neuropsychological test.

Neuropsychological testing may be necessary for persons with documented neurologic disease or injury (e.g., traumatic brain injury, stroke) when there is uncertainty about the degree of impairment, or when an organic deficit is present but information on anatomic location and extent of dysfunction is required.  An organic deficit is defined as a symptomatic manifestation of structural cerebral or systemic medical pathology, as opposed to being considered psychological or emotional in nature (functional).  Such testing can also be used to systematically track progress in rehabilitation after brain injury or other neurological disease.  Serial assessment in nonprogressive conditions, such as head injury, documents the patient’s rate of recovery and potential for returning  to work.

Neuropsychological testing is used in persons with documented changes in cognitive function to differentiate neurologic diseases (i.e., one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging).  The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture.  Neuropsychological testing may be particularly helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal.  The differential diagnosis of incipient dementia from depression is a casein point, particularly when computed tomography (CT) fails to yield definitive results.

Neuropsychological testing may be indicated in persons with epilepsy or hydrocephalus.  Neuropsychological testing is used in these patients to monitor the efficacy and possible cognitive side effects of drug therapy (e.g., new anti-convulsant drug therapy) by comparing baseline performance with subsequent testing performance.  Neuropsychological testing is also used to assess post-surgical changes in cognitive functioning to guide further treatment services.  Preferably, these tests should be administered by a certified psychologist trained to conceptualize the neuro-anatomical and the neuro-behavioral implications of the diagnostic entities under consideration and who is capable of interpreting patterns of test scores in view of principles of lateralization and localization of cerebral function.

Neuropsychological testing is used for initial evaluation of cognitive deterioration associated with acquired immunedeficiency syndrome (AIDS), and for re-evaluation of persons with AIDS who show further deterioration, to distinguish between organic-based deterioration and deterioration from depression of chonic illness, in order to direct appropriate treatment.

Neuropsychological testing is also used in the initial evaluation of cognitive deterioration associated with Alzheimer’s disease.  It is also used for persons diagnosed with Alzheimer’s disease receiving medication for dementia, to evaluate deterioration in cognitive functioning to distinguish between diminished effect of the medication and organic worsening of the disease.  Serial administration of parallel forms of memory tests has been employed to investigate the effects of cholinergic agents and other drugs on dementia of the Alzheimer’s type.  Available medications for Alzheimer disease provide only a temporary cessation of the organic deterioration associated with Alzheimer’s disease, such that repeat testing may be necessary to aid in deciding whether or not to increase or discontinue the drug.

Neuropsychological testing typically takes up to 8 hours to perform, including administration, scoring and interpretation.  It is not necessary, as a general rule, to repeat neuropsychological testing at intervals less than 3 months apart.  In general, neuropsychological testing may not be as helpful in individuals over 65 years of age.

Psychological and neuropsychological testing has been used to assess of the neurotoxic effects of alcohol and/or drug abuse or dependence.  Chronic alcohol abuse can result in cognitive and memory defects which resolve to a varying degree depending on the duration of abstinence and the extent of neuronal loss or atrophy.  However, it is inappropriate to perform psychological and neuropsychological testing in a patient to assess the neurotoxic effects of alcohol or drug abuse or dependence during the detoxification period or within the early period of abstinence from the offending drug.  The results of psychological and neuropsychological assessment are unreliable when an individual is actively abusing alcohol or drugs and for some period of time after the acute phase of alcohol or drug withdrawal.

Psychological and neuropsychological testing has been used in the educational context in children with suspicion of a learning disorder leading to changes in school performance, so as to differentiate between mental subnormality, emotional disturbance, and the specific learning disabilities in speech and reading (e.g., dyslexia).  Psychological and neuropsychological testing are also used to develop a specialized treatment plan to help the child improve the performance of these cognitive functions leading to a better performance in school, work, and personal relationships.  However, psychological and neuropsychological testing for educational reasons is not covered, as standard Aetna benefit plans exclude educational testing.  In addition, psychological and neuropsychological testing performed for educational reasons is not considered treatment of disease.  This testing is usually provided by school systems under applicable state and federal rules.

Psychological and neuropsychological testing of children for the purpose of diagnosing attention deficit/hyperactivity disorder (ADHD) is not necessary, unless there is strong evidence of a possible neurological disorder.  There are few medical conditions which present with ADHD-like symptoms and most patients with ADHD have unremarkable medical histories.  In general, attention deficit disorders are best diagnosed through a careful history and the use of structured clinical interviews and dimensionally based rating scales.  Most psychologists obtain behavior ratings at home from the parents and at school from the teacher.  Examples of rating scales commonly used by psychologists are the Achembach Child Behavior Checklist,Connors Rating Scales, and the ADHD Symptoms Rating Scale.

Psychological and neuropsychological testing may used to assess functional competence in relationship to legal matters.  However, such use is not considered treatment of disease.  Psychological and neuropsychological testing performed as part of a research program is also not considered treatment of disease.

The types and numbers of neuropsychological tests given for each condition is not standardized.  Most psychologists will perform an in depth interview after the patient has filled out a standardized questionaire asking questions about history, symptoms and functioning, and based on this evaluation the psychologist will plan the testing regimen.

While neuropsychological testing may be useful to distinguish cognitive decline due to dementia from cognitive decline due to depression, its use in patients with chronic fatigue syndrome (CFS) has yet to be established.  Current evidence-based guidelines on chronic fatigue syndrome include no recommendation for neuropsychological testing in CFS.

Michiels and Cluydts (2001) reviewed the current status of neurocognitive studies in patients with CFS.  The authors concluded that the current research shows that slowed processing speed, impaired working memory and poor learning of information are the most prominent features of cognitive dysfunctioning in patients with CFS.  Furthermore, to this date no specific pattern of cerebral abnormalities has been found that uniquely characterizes CFS patients.  There authors stated that there is no overwhelming evidence that fatigue is related to cognitive performance in CFS, and researchers agree that their performance on neuropsychological tasks is unlikely to be accounted solely by the severity of the depression and anxiety.

Claypoole et al (2007) noted that variable reports of neuropsychological deficits in patients with CFS may be partly attributable to methodological limitations.  In this study, these researchers addressed these limitations by controlling for genetic and environmental influences and by assessing the effects of co-morbid depression and mode of illness onset.  Specifically, these researchers performed a co-twin control study of 22 pairs of monozygotic twins, in which 1 twin met strict criteria for CFS and the co-twin was healthy.  Twins underwent a structured psychiatric interview as well as comprehensive neuropsychological assessment evaluating 6 cognitive domains.  Results indicated that twin groups had similar intellectual and visual memory functioning, but fatigued twins exhibited decreases in motor functions (p = 0.05), speed of information processing (p = 0.02), verbal memory (p = 0.02), and executive functioning (p = 0.01).  Major depression did not affect neuropsychological functioning among fatigued twins, although twins with sudden illness onset demonstrated slowed information processing compared with those with gradual onset (p = 0.01).  Sudden onset CFS was associated with reduced speed of information processing.  If confirmed, these findings suggested the need to distinguish illness onset in future CFS studies and may have implications for treatment, cognitive rehabilitation, and disability determination.

Binder et al (2004) reviewed several illnesses that expressed somatically, but do not have clearly demonstrated pathophysiological origin and are associated with neuropsychological complaints.  Among them are CFS, non-epileptic seizures, fibromyalgia, Persian Gulf War unexplained illnesses, toxic mold and sick building syndrome, and silicone breast implant disease.  Some of these illnesses may be associated with objective cognitive abnormalities, but it is not likely that these abnormalities are caused by traditionally defined neurological disease.  Instead, the cognitive abnormalities may be caused by a complex interaction between biological and psychological factors.

Neuropsychological Testing for Evaluation of Migraineurs:

Gil-Gouveia and colleagues (2016) noted that evidence of attack-related cognitive dysfunction in migraine is growing.  Controversy exists on whether cognitive dysfunction, mainly executive, may persist between attacks.  Measuring the impact of cognitive function is gaining importance in clinical and research settings in migraine.  These investigators compared the performance of inter-ictal migraine patients to controls in an assembled neuropsychological battery focused on executive functions and studied the practice effect of its repeated applications.  Assembly of the battery that was then applied twice within 6 weeks to inter-ictal migraineurs and matched healthy controls.  Migraine patients (n = 24) and controls (n = 24) had similar performance in both applications of the battery.  There was a slight practice effect between the 1st and 2nd evaluation, significant in Stroop Interference test (p = 0.002, multiplicity corrected); a meaningful score change was determined for each raw test scores.  The authors concluded that inter-ictal migraineurs and controls performance was identical in a brief cognitive battery focused on executive functions; and repeated applications produced a practice effect that was quantified.

In a randomized, cross-sectional, within subject study, Huang and associates (2017) evaluated the changes in the cognitive performance of migraine patients using a comprehensive series of cognitive/behavioral and electrophysiological tests.  A total of 34 patients with migraine (6 men, 28 women, average age of 36 years) were included.  Migraineurs performed worse in the majority of the Montreal Cognitive Assessment (MoCA) (p = 0.007) compared to the healthy subjects, significantly in language (p = 0.005), memory (p = 0.006), executive functions (p = 0.042), calculation (p = 0.018) and orientation (p = 0.012).  Migraineurs had a lower score on the memory trial of the Rey-Osterrieth complex figure test (ROCF) (p = 0.012).  The P3 latency in Fz, Cz, Pz was prolonged in migraineurs compared with the normal control group (p < 0.001).  In addition, these researchers analyzed significant correlations between MoCA score and the duration of migraine.  They also observed that a decrease in the MoCA-executive functions and calculation score and in the ROCF-recall score were both correlated to the frequency of migraine.  Migraineurs were more anxious than healthy subjects (p = 0.001), which was independent of cognitive testing.  Differences were unrelated to age, gender and literacy.  The authors concluded that these findings suggested the existence of brain dysfunction during attacks of migraine, which be related to the duration and frequency of a migraine attack.

1. the study sample (n = 34)  limited the ability to examine the effects of gender, age and education,
2. a previous study has shown that migraineurs with aura tended to exhibit even less decline over time than migraineurs overall.  These researchers did not find differences in mean cognitive scores between migraineurs with and without aura.  However, this was likely to due to the sample sizes and resulting low statistical power.  de Tommaso et al (2014) found that the changes in brain responsivity were associated with various stages of the migraine cycle, since migraine patients appeared to have a response augmentation and poor habituation that normalizes just before/during attacks.  In this study, patients were observed outside migraine attacks, but they could be at different points of a migraine cycle.  These investigators did not record the last time that they had a migraine attack, and
3. these researchers did not observe the cognition of migraine patients at multiple time-points, which limited them from examining the change in cognitive function over time.

Foti  and co-workers (2017) stated that migraine is considered a disabling disorder with highly prevalence in population.  Recent studies report that migraine patients have a cognitive decline associated to structural brain alterations.  These investigators searched on PubMed and Web of Science databases and screening references of included studies and review articles for additional citations.  From 519 studies identified, only 16 met the inclusion criteria.  All studies were conducted on 1,479 migraineurs (190 non-migraine headache and 11,978 control subjects) and examined the association between migraine and cognitive impairment.  The results were discordant.  While cognitive deficits during the attack of migraine are now recognized, only few studies confirmed the presence of cognitive impairment in migraine patients.  The authors concluded that given the prevalence of migraine in the population (especially among women), and the early age of the population, an association between migraine and cognitive impairment could have substantial public health implications.  They stated that future studies should determine if specific migraine characteristics (e.g., attack frequency) may impact the association between migraine and cognitive decline.

The above policy is based on the following references: