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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.

Covered Neuropsychological Services

Neuropsychological Assessment

Neuropsychological assessment is a specialized clinical assessment of the recipient’s underlying cognitive abilities related to thinking, reasoning and judgment. The assessment must be conducted by a qualified neuropsychologist. The following components are included in the service. Do not bill for them separately:

  1. Face-to-face interview
  2. Interpretation of test results
  3. Preparation and completion of a written report
  4. Face-to-face feedback provided to recipient as part of the assessment process

A recipient is eligible for a neuropsychological assessment if at least one of the following criteria is met:

  1. A brain disorder is known or strongly suspected to exist because of the patient’s medical history or a neurological evaluation. Examples of brain disorders include the following:
    1. Brain disorder resulting from past significant head trauma
    2. Brain tumor
    3. Stroke
    4. Seizure disorder
    5. Multiple sclerosis
    6. Neurodegenerative disorder
    7. Brain disorder resulting from significant exposure to neurotoxins
    8. Brain disorder resulting from central nervous system infection
    9. Metabolic or toxic encephalopathy
    10. Fetal alcohol syndrome
    11. Congenital malformations of the brain
  2. 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. In children or adolescents, significant delays in acquiring academic skill or poor attention relative to peers
    6. In children or adolescents, significant plateau in expected development of cognitive, social, emotional or physical function relative to peers
    7. 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

Neuropsychological testing means administering standardized tests and measures designed to evaluate the recipient’s ability to:

  1. Attend to, process, interpret, comprehend, communicate, learn and recall information
  2. Use problem solving and judgment

Neuropsychological testing must be:

  1. Administered or clinically supervised by a qualified neuropsychologist
  2. Validated in a face-to-face interview between the recipient and a qualified neuropsychologist

A recipient is eligible for neuropsychological testing when the recipient has one of the following:

  1. A significant mental status change that is not a result of a metabolic disorder and has failed to respond to treatment
  2. In children or adolescents, a significant plateau in expected development of cognitive, social, emotional or physical function relative to peers
  3. In children or adolescents, a significant inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional or physical demands
  4. A significant behavioral change, memory loss or other organic brain injury
  5. Suspected neuropsychological impairment in addition to functional psychopathology
  6. Traumatic brain injury
  7. Stroke
  8. Brain tumor
  9. Substance abuse or dependence
  10. Cerebral anoxic or hypoxic episode
  11. Central nervous system infection or other infectious disease
  12. Neoplasms or vascular injury of the central nervous system
  13. Neurodegenerative disorder
  14. Demyelinating disease
  15. Extrapyramidal disease
  16. Exposure to systemic or intrathecal agents or cranial radiation known to be associated with cerebral dysfunction
  17. Systemic medical condition known to be associated with cerebral dysfunction, including renal disease, hepatic encephalopathy, cardiac anomalies, sickle cell disease and related hematologic anomalies, and autoimmune disorders such as lupus erythematosus or celiac disease
  18. Congenital, genetic, or metabolic disorder known to be associated with cerebral dysfunction, such as phenylketonuria, craniofacial syndromes or congenital hydrocephalus
  19. Severe or prolonged malnutrition or malabsorption syndrome
  20. Condition presenting in a manner making it difficult for a clinician to distinguish between the following:
    1. the neurocognitive effects of a neurogenic syndrome (such as dementia or encephalopathy) and
    2. a major depressive disorder when adequate treatment has not resulted in improvement in neurocognitive functioning, or another disorder (for example, autism, selective mutism, anxiety disorder, or reactive attachment disorder)

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 2018
  3. Minnesota Department of Human Services Care Provider Manual – Neuropsychological Services Updated 08-19.2016

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Policy activity

  • 09/19/2017 - Date of origin
  • 10/01/2017 - Effective date
Review date
  • 06/2018

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