Aetna considers neuropsychological testing (NPT) medically necessary when provided to aid in the assessment of cognitive impairment due to medical or psychiatric conditions. Examples of situations for which NPT may be medically necessary include, but are not limited to:
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:
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 - Pervasive Developmental Disorders).
NPT is considered not medically necessary for diagnosis and management of persons with chronic fatigue syndrome. (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.
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.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|96101||Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report|
|96102||Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face|
|96103||Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report|
|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), 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 (eg, 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 administering tests to the patient and time interpreting test results|
|96119||Neuropsychological testing (eg, 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 (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report|
|96125||Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report|
|ICD-9 codes covered if selection criteria are met:|
|290.0 - 290.43, 294.8||Dementia|
|310.1||Personality change due to conditions classified elsewhere|
|310.89||Other specified nonpsychotic mental disorders following organic brain damage|
|330.0 - 331.9||Cerebral degeneration|
|438.0||Late effects of cerebrovascular disease, cognitive deficits|
|780.97||Altered mental status|
|781.8||Neurologic neglect syndrome|
|800.00 - 804.99||Fracture of skull|
|850.0 - 854.19||Intracranial injury|
|905.0||Late effect of fracture of skull and face bones|
|907.0||Late effect of intracranial injury without mention of skull fracture|
|959.01||Head injury, unspecified|
|ICD-9 codes not covered for indications listed in the CPB:|
|303.00 - 305.92||Alcohol dependence syndrome, drug dependence, and nondependent abuse of drugs [active abuse, having withdrawal symptoms, or recently entering recovery]|
|314.00 - 314.01||Attention deficit disorder|
|315.00 - 315.9||Specific delays in development|
|780.71||Chronic fatigue syndrome|
|V72.83||Other specified pre-operative examination|
|V72.84||Pre-operative examination, unspecified|
|V79.0 - V79.9||Special screening for mental disorders and developmental handicaps [when billed alone indicates no signs or symptoms]|
|V80.01 - V80.09||Special screening for neurological conditions [when billed alone indicates no signs or symptoms]|
|Other ICD-9 codes related to the CPB:|
|042||Human immunodeficiency virus [HIV] disease|
|259.0||Delay in sexual development and puberty, not elsewhere classified|
|290.0 - 302.9, 306.0 - 313.9, 314.2 - 314.9, 316 - 319||Other mental disorders|
|332.0 - 332.1||Parkinson's disease|
|345.00 - 345.91||Epilepsy and recurrent seizures|
|348.0 - 348.9||Other conditions of brain|
|433.00 - 438.9||Occlusion and stenosis of precerebral arteries, occlusion of cerebral arteries, transient cerebral ischemia, acute, but ill-defined, cerebrovascular disease, other and ill-defined cerebrovascular disease, and late effects of cerebrovascular disease|
|741.00 - 741.03||Spina bifida with hydrocephalus|
|758.0 - 758.9||Chromosomal anomalies|
|963.8||Poisoning by heavy metal anti-infectives|
|V79.0 - V79.9||Special screening for mental disorders and developmental handicaps|