Medical Affairs Policy

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1 Medical Affairs Policy Service: Neuropsychological Testing PUM Implemented Interim 12/06/12, 03/28/13, 04/04/14, 04/17/15 Arise/WPS Policy 03/07/14, 03/13/15 Committee Approval Revised 11/26/12, 03/07/14, 03/13/15 (changes made) Reviewed 12/28/09, 07/27/10, 09/16/11, 03/08/13 (no changes) Developed 12/28/09 WPS Policy 03/08/13, 03/07/14, 03/13/15 Committee Approval Disclaimer: Benefit plans vary in coverage and some plans may not provide coverage for certain services listed in these policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, an explanation of benefits, or a guarantee of payment. Description: Neuropsychological tests (NPT) are evaluations designed to determine the functional consequences of known or suspected brain injury through testing of the neurocognitive domains responsible for language, perception, memory, learning, problem solving and adaptation. These tests are carried out on patients who have suffered neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. They are objective and quantitative in nature and require patients to directly demonstrate their level of competence in a particular cognitive domain. They are not a substitution for clinical interviews, medical, neurologic, or psychological examinations, or other diagnostic procedures used to diagnose neuropathology. Rather, when used judiciously in patients with particular neuropsychological problems, they can be an important tool in making specific diagnoses or prognoses after neurologic injury, to aid in treatment planning, and to address questions regarding treatment goals, efficacy, and patient disposition. Neuropsychological testing is also used to differentiate psychiatric from neurological disorders. Determining what specific brain functions are compromised, as well as which cognitive functions are intact, can help differentiate between the two types of disorders and predict the effects of remediation. Page 1 of 7

2 Indications of Coverage: Note: The provider performing the testing must be a covered provider under the illness and/or mental health benefit of the certificate, depending on the condition that is being evaluated. A. Neurobehavioral status exam is considered medically necessary to evaluate possible issues with cognitive functioning, determine the need for neuropsychological testing, and evaluate the treatment efficacy of a cognitive issue previously diagnosed. (Not an all-inclusive list) B. Neuropsychological testing (NPT) is considered medically necessary for the purpose of directing further medical care when all of the following criteria are met: 1. When at least one medical condition or situation is present such as but not limited to: a. Head injury (open or closed) b. Stroke c. Brain tumor d. Cerebral anoxic or hypoxic episode e. Severe central nervous system infection f. Neoplasm or vascular injury of the central nervous system g. Neurodegenerative disorders h. Demyelinating diseases (e.g., multiple sclerosis) i. Extrapyramidal diseases (e.g., Parkinson s, Huntington s) j. Metabolic encephalopathy after disease stabilization k. Exposure to agents known to be associated with neurodysfunction, (e.g., intrathecal methotrexate, cranial irradiation, lead poisoning). Occupational hazards such as chronic solvent exposure (if a covered benefit) l. A psychogenic diagnosis has been ruled out, or is not responsive to appropriate treatment and testing is requested to provide a differential diagnosis between a psychogenic and neurogenic syndrome that is affecting neurocognitive function. (e.g. Complex ADHD with anxiety disorder; autism or other neurodevelopmental disorders, if the diagnosis is in question). m. The presence of unusual, complex, or co-morbid symptoms requiring clarification that only can be accomplished through neuropsychological testing 2. The neuropsychological tests employed are likely to produce the diagnostic and treatment clarification required and 3. One of the following conditions or situations: 1) When there has been a significant mental status change that is not due to a metabolic disorder (such as a diabetic hypoglycemic episode) and the change has not responded to acute medical therapy, OR 2) When there has been a significant behavioral change, memory loss, inability to perform simple calculations or abstract tasks, organic brain Page 2 of 7

3 injury, sensory illusions, or other serious circumscribed cognitive deficits, AND a comprehensive medical and psychological evaluation has been unable to establish a diagnosis OR 3) Neurologically complicated cases of Attention Deficit Disorder with significant co-morbidities when, despite a comprehensive medical and psychological evaluation, the diagnosis has not been clearly established, or appropriate medical therapy has failed, OR 4) Re-evaluations of an individual with decreasing cognitive function is requested due to a neurological disorder if the results are intended to guide treatment. C. Non-baseline NPT testing by a physician, psychologist or licensed mental health professional for management of concussion is considered medically necessary Limitations of Coverage: A. Review contract and endorsements for exclusions and prior authorization or benefit requirements. B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, deny as experimental or investigative. C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary. NPT is considered not medically necessary for any of the following: Note: Member certificate benefits and exclusions may also apply 1. There is no documentation of thorough medical evaluation by a physician (primary care, specialty, or both) prior to the request 2. Request is solely to confirm the working diagnosis and treatment plan 3. There is no documentation of how the testing will benefit the development of the treatment plan. 4. Uncomplicated attention deficit disorder with or without hyperactivity (ADD/ADHD) 5. When the individual has been diagnosed with a neuro-developmental disorder (for example, autism or Asperger s syndrome) unless coverage is required by Federal or State mandate 6. Testing is for requested educational purposes, such as assessment of learning style, learning disability, academic ability, development of an educational plan, or for uncomplicated Attention Deficit Disorder Page 3 of 7

4 7. Testing is for the purpose of obtaining or maintaining employment, or improving job performance. 8. Testing is ordered or requested pursuant to a condition of parole, probation, or in any way related to judicial or legal purposes 9. Testing is required or requested by a third party, such as a school or place of employment. 10. Testing is solely for documenting treatment efficacy. (Gordon Continuous Performance Test, Test of Variables of Attention, etc.) 11. Re-testing done within one year without clear clinical justification 12. Baseline neuropsychological testing in asymptomatic persons is considered not medically necessary. Documentation Required: Office notes and reports indicating: 1. The referral source, and to whom the results will be conveyed. 2. The test(s) proposed for evaluation. 3. The amount of time being requested to complete the evaluation. 4. The treatment planning issues that testing is expected to clarify. 5. A summary of clinical information, including differential diagnosis, prior evaluation performed to date, and therapies or remediation attempted. Rationale: Concussion, ImPACT Testing and Post-concussion Syndrome: Neuropsychological testing is increasingly being used in the area of sport-related concussion to assist in return to play decisions. The question as to whether or not such testing is associated with improved clinical outcomes is unclear. The evidence for the clinical utility of a computerized test such as ImPACT, reveals insufficient support to suggest that use of the test is associated with a change in clinical outcome. Despite the uncertainty, clinical evolution clearly shows wide acceptance of ImPACT testing. When evaluating and advising concussed athletes when to return to play, ImPACT test results should not be the determining factor. There is insufficient evidence that baseline tests influence physician decision-making or outcomes of treatment of concussion. Non-baseline testing for concussion is allowed. There is a lack of consensus in the literature regarding traumatic brain injury stratification, post-concussion syndrome symptoms, onset of symptoms and duration of symptoms for persistence to be defined as chronic. Symptoms generally may include persistent headache, fatigue, irritability, sleep disturbance, memory difficulty, intolerance Page 4 of 7

5 of stress, and personality change. Patients with persistence of symptoms, or significant change from pre-head injury symptoms may require neuropsychological testing. Neuropsychological testing and Attention Deficit Disorder: In accordance with the National Association of Pupil Services Administrators, a differentiation is necessary between neuropsychological and neuroeducational assessment. An educational or school psychologist who has been trained in neuropsychological assessment conducts the neuroeducational evaluation. The evaluation is conducted to assess brain behavior relationships as they relate to educational consequences and functioning. The neuroeducational evaluation includes, but is not limited to the following areas of assessment: Intellectual Memory & learning Executive Functioning Emotional Functioning Achievement Visual Organization Language The neuroeducational evaluation provides the school with recommendations that are educationally based. Interpretations of these results assist school personnel in the development of an appropriate Individual Educational Plan. The neuropsychological evaluation is conducted by a neuropsychologist. This evaluation assesses brain behavior relationships across the same areas noted in a neuroeducational evaluation. The neuropsychological evaluation draws conclusions about the presence and extent of brain damage and laterality. Therefore, WPS subscribes to the premise that the diagnosis of Attention Deficit Disorder can be accomplished using clinical evaluation procedures including an interview, review of the patient s medical, psychological, academic, and/or employment records, information from collateral sources, screening inventories, substance abuse history and physical exam. References: 1. American Academy of Clinical Neuropsychology. American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol Mar; 21(2): American Academy of Pediatrics (AAP). Committee on Quality Improvement, Subcommittee on Attention Deficit/Hyperactivity Disorder. Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention Deficit/Hyperactivity Disorder. Pediatrics. 2000;105(5): Page 5 of 7

6 3. American Psychiatric Association. Practice guideline for the Psychiatric Evaluation of Adults. Second Edition. June Available at: Accessed: 29 Aug American Psychological Association, Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association. Available at: Accessed: 29 Aug Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH Jr, Dawson G, Gordon B, Gravel JS, Johnson CP, Kallen RJ, Levy SE, Minshew NJ, Ozonoff S, Prizant BM, Rapin I, Rogers SJ, Stone WL, Teplin SW, Tuchman RF, Volkmar FR. 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 Aug 22;55(4): Heilbronner RL, Sweet JJ, Attix DK, Krull KR, Henry GK, and Hart RP. Official position of the american academy of clinical neuropsychology on serial neuropsychological assessments: the utility and challenges of repeat test administrations in clinical and forensic contexts The Clinical Neuropsychologist, 24:8, Available at: Accessed: 29 Aug Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. 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 May 8;56(9): Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attentiondeficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry Jul;46(7): Sweet, Jerry J., et al, National Academy of Neuropsychology/Division 40 of the America Psychological Association Practice Survey of Clinical Neuropsychology in the United States, Part I: Practitioner and Practice Characteristics, Professional Activities and Time Requirements: The Clinical Neuropsychologist, 2002, Vol. 2, pp Sweet, Jerry J., et al, National Academy of Neuropsychology/Division 40 of the America Psychological Association Practice Survey of Clinical Neuropsychology in the United States, Part II: Reimbursement Experiences, Practice economics, Billing Practices, and Incomes: Archives of Clinical Neuropsychology, 18 (2003) pp Page 6 of 7

7 11. Lundin, Karen A., DeFilippis, Nick A., Proposed Schedule of Usual and Customary Test Administration Times: The Clinical Neuropsychologist, 1999, Vol. 13, No 4, pp Camara, Wayne J., et al, Psychological Test Usage: Implications in Professional Psychology: Professional Psychology: Research and Practice: 2000, Vol 31, No 2, pp Institute for Clinical Systems Improvement: Health Care Guidelines: Diagnosis and Management of ADHD in Primary Care for School Age Children and Adolescents, Sixth Edition, January, 2005 pp Hurley, Gina: National Association of Pupil Services Administrators: The Use of Neuroeducational Evaluations in Public Schools, Hayes Search and Summary: Gordon Diagnostic System to aid in the assessment of ADHD, February 16, Kirkwood MW, Randolph C, Yeates KO. Returning pediatric athletes to play after concussion: the evidence (or lack thereof) behind baseline neuropsychological testing. Acta Paediatr Sep;98(9): Mayers LB, Redick TS. Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: psychometric issues. J Clin Exp Neuropsychol. 2012;34(3): Epub 2011 Dec McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November Clin J Sport Med May;19(3): Hayes Search & Summary. Uses for Immediate Post-Concussion Assessment and Cognitive Testing (Impact) after Sports-Related Head Injury. May 16, UpToDate Concussion and mild traumatic brain injury. Literature review current through: Feb This topic last updated: Jul 3, UpToDate Postconcussion Syndrome. Literature review current through: Jan This topic last updated: Oct MCG 19 th Edition: ORG: B-805-T (BHG) Neuropsychological Testing. 23. Hayes Medical Technology Directory. Computerized Neurocognitive Testing (CNT) for Sports-Related Head Injury. Publication Date: January , Annual Review Jan 26, Approved by the Medical Director Page 7 of 7