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Coverage criteria policies

Neuropsychological testing- Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for neuropsychological testing. Network rules apply.

This coverage criterion does not apply to psychological testing.

Evaluations will be performed periodically to identify policy adherence.

Coverage

Neuropsychological testing is covered when ordered by a psychologist or psychiatrist for a behavioral health condition or a neurologist (or the appropriate physician specialist) for a medical disorder for the purpose of diagnosis or treatment of neuropsychological disorders.

  • Neuropsychological testing for medical conditions is covered under the medical benefit.
  • Neuropsychological testing for behavioral health conditions is covered under the behavioral health benefit.

Indications that are covered

Neuropsychological testing is considered medically necessary when there has been either #1 or #2 below in addition to at least one element under #3.

  1. Cognitive or behavioral symptoms suggest the recipient has an organic condition that cannot be readily attributed to functional psychopathology. Examples include the following:
    1. Poor memory or impaired problem solving
    2. Change in mental status evidenced by lethargy, confusion or disorientation
    3. Deterioration in level of functioning
    4. Marked behavioral or personality change
    5. Organic brain injury
    6. In children or adolescents, significant delays in acquiring academic skill or poor attention relative to peers
    7. In children or adolescents, significant plateau in expected development of cognitive, social, emotional or physical function relative to peers
    8. In children or adolescents, significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional or physical demands
  2. A significant mental status change as noted on a Mental Status Examination that is not a result of a metabolic disorder which has not responded to treatment; (This excludes changes due to a metabolic disorder.) and
  3. In addition to at least one of the following:
    1. Traumatic brain injury
    2. Stroke
    3. Brain tumor
    4. Cerebral anoxic or hypoxic episode
    5. Neoplasms or vascular injury of the CNS
    6. Neurodegenerative disorders
    7. Demyelinating disease/Multiple Sclerosis
    8. Extrapyramidal disease
    9. Epilepsy/Seizure Disorder
    10. Cranial facial surgery
    11. Sickle cell
    12. Hemophilia
    13. Exposure to intrathecal agents or cranial radiation known to be associated with cerebral dysfunction
    14. Brain disorder resulting from significant exposure to neurotoxins
    15. Brain disorder resulting from central nervous system infection
    16. Metabolic or toxic encephalopathy
    17. Fetal alcohol syndrome
    18. Congenital malformations of the brain
    19. Difficulty distinguishing between the neurocognitive effects of a neurogenic syndrome such as dementia vs. a Major Depressive Disorder when adequate treatment for Major Depressive Disorder has not resulted in improvement in neurocognitive function

Indications that are not covered

Neuropsychological testing is not covered for the following conditions:

  • Primarily for educational purposes
  • Primarily for vocational counseling or training
  • For personnel or employment testing
  • As a routine battery of psychological tests given at inpatient admission or continued stay
  • For legal or forensic purposes

Definitions

Neuropsychology is a subspecialty within the field of psychology which investigates the correlation between experience and behavior and the basic changes that may be caused by the nervous system.

A neuropsychological disorder is a disturbance of normal brain function due to organic brain disease or trauma, associated with one or more of the following impairments: cognitive, behavioral, or emotional.

Neuropsychological testing is designed to assess higher cortical functions including thought process and organization, reasoning or judgment. These tests are used in diagnosing brain dysfunction or damage and central nervous system disorders or injury. Neuropsychological testing is conducted by a board certified neuropsychologist.

Psychological testing is designed to provide information about mental health conditions including personality, intellectual and emotional functioning. Psychological testing is not the same as neuropsychological testing. Psychological testing is conducted by a licensed psychologist

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

    Codes

    Description

    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 administering tests to the patient and time interpreting these 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

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Rules, part 9505.0372, subparts 2 and 3 (Covered Services) https://www.revisor.mn.gov/rules/?id=9505.0372
  2. Minnesota Rules, part 9505.0370, subparts 22 and 23 (Definitions) https://www.revisor.mn.gov/rules/?id=9505.0370
  3. Minnesota Health Care Provider Manual – Neuropsychological Services Revised 08-19.2016

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Policy activity

  • 09/19/2017 - Date of origin
  • 10/01/2017 - Effective date

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