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Neuropsychological and Psychological Testing
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Defines Aetna's medical necessity, limitations, coding, and coverage stance for neuropsychological (NPT) and psychological testing (PT) for members when specific clinical criteria are met; applies to providers submitting claims under Aetna benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria
NPT general criteria
Neuropsychological testing (NPT) is considered medically necessary when ALL of the following are met:
Illustrative medically necessary indications
Examples of medically necessary indications for NPT include (not limited to):
PT/NPT for psychiatric indications
NPT or PT to enhance psychiatric/psychotherapeutic treatment outcomes is considered medically necessary when:
ADHD / developmental disorder testing
Condition-specific coverage considerations
Coverage stance and evidence considerations summarized by condition
Current evidence-based guidelines include no recommendation for neuropsychological testing in CFS.
Practice effect and timing relative to migraine cycle may influence results; small sample sizes limit certainty.
Specific CNADs demonstrated strongest psychometric support; documentation should include device name and supporting evidence.
Clinical utility of neurodiversity tests is limited and not well-established in the literature.
Neuropsychological testing (NPT) and psychological testing (PT) performed for educational purposes, employment screening, disability qualification, legal/court-related purposes, or as part of a research protocol are not considered treatment of disease and therefore are not covered under this Clinical Policy Bulletin. These services are typically provided outside the medical benefit (for example, by school systems or through employment processes) and coverage should be confirmed against the member’s specific plan documents.
NPT is specifically listed as not medically necessary for the diagnosis and management of chronic fatigue syndrome (CFS) and for routine evaluation of migraineurs. (Note: PT may be medically necessary to help differentiate CFS from psychiatric diagnoses when PT criteria are otherwise met.)
NPT or PT is considered not medically necessary when the member is actively abusing substances, experiencing acute withdrawal, or has recently entered recovery, because test results in these states may be invalid. Related ICD-10 codes for active substance use/withdrawal are identified in the policy as not covered for those indications.
Routine neuropsychological testing for chronic fatigue syndrome is not supported by current evidence-based guidelines and therefore is not routinely indicated. Likewise, broad use of neurodiversity screening instruments as standalone diagnostic tools lacks evidence of clinical value; such tests identify traits and should prompt referral for formal diagnostic evaluation rather than serving as definitive diagnostic assessments.
Clinical Policy Bulletins are informational documents developed to assist in administering plan benefits and do not constitute a contract or an offer of coverage. Coverage, prior authorization requirements, and benefit limits are determined by the member’s specific plan documents and program provisions; providers should verify eligibility and authorization requirements with Aetna.
Use of computerized neuropsychological assessment devices (CNADs) for screening asymptomatic or healthy individuals and for certain monitoring or screening indications (for example, some MS-related uses) is considered experimental/investigational because effectiveness has not been established. When CNADs are used, documentation should support the device’s psychometric validity and the clinical rationale for its use rather than substituting for comprehensive conventional assessment.
Neuropsychological testing ordered solely to evaluate for chronic fatigue syndrome or solely to provide a neurodiversity “diagnosis” without subsequent diagnostic follow-up or a clear clinical indication is considered not medically necessary. The policy emphasizes that neurodiversity screening tools lack definitive diagnostic value and should be followed by appropriate diagnostic assessment when clinically indicated.
Coding and Visit Limits
| 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. |
| 96121 | Neurobehavioral status examination, by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure). |
| 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. |
| 96130 | Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed. |
| 96131 | Psychological testing evaluation services additional hour (see code set). |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed. |
| 96133 | Neuropsychological testing evaluation services additional hour (see code set). |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method. |
| 96137 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests (additional). |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, two or more tests. |
| E75.00-E75.09 | GM2 gangliosidosis |
| E75.10-E75.19 | Other and unspecified gangliosidosis |
| E75.23 | Krabbe disease |
| E75.25 | Metachromatic leukodystrophy |
| E75.29 | Other sphingolipidosis |
| E75.4 | Neuronal ceroid lipofuscinosis |
| F01.50-F01.C4 | Vascular dementia |
| F03.90-F03.C4 | Unspecified dementia |
| F07.0 | Personality change due to known physiological condition |
| F07.89 | Other personality and behavioral disorders due to known physiological condition |
| F10.10-F19.99 | Mental and behavioral disorders due to psychoactive substance use (active abuse, withdrawal, recent recovery) |
| G43.001-G43.919 | Migraine |
| R53.82 | Chronic fatigue, unspecified |
| Z01.812 | Encounter for preprocedural laboratory examination |
| Z01.818 | Encounter for other preprocedural examination |
| Z13.40-Z13.49 | Screening for certain developmental disorders in childhood (when billed alone indicates no signs/symptoms) |
| Z13.850 | Encounter for screening for traumatic brain injury (when billed alone indicates no signs/symptoms) |
| Z13.858 | Encounter for screening for other nervous system disorders (when billed alone indicates no signs/symptoms) |
| Z13.89 | Encounter for screening for other disorder (mental disorder screening) (when billed alone indicates no signs/symptoms) |
| G31.84 | Mild cognitive impairment, so stated |
Provider Actions and Authorization
Prior authorization for tests lacking guideline support
Prior authorization may be appropriate when neuropsychological testing is ordered for conditions that lack guideline support (for example, chronic fatigue syndrome, routine screening of asymptomatic individuals, or certain computerized test uses for MS) — providers should obtain prior authorization when plan criteria are not clearly met.
- Examples: testing for chronic fatigue syndrome (CFS) — guideline support is absent; computerized neuropsychological assessment devices (CNADs) for screening/monitoring when psychometric support is limited.
Verify plan authorization requirements
Providers must verify member coverage and any plan-specific prior authorization requirements before scheduling testing. Authorization and coverage are determined by the member’s benefit plan and program provisions; lack of documented benefit coverage or required prior authorization may result in claim denial.
- Check the member’s medical vs mental health benefit for NPT/PT coverage.
- Confirm whether preauthorization is required for the specific CPT codes and indication being billed.
CFS testing denial risk
Use of neuropsychological testing for chronic fatigue syndrome (CFS) lacks guideline support; claims for NPT for CFS are at increased risk of denial unless documentation clearly supports a covered indication or meets medical necessity criteria.
- CPT codes billed for CFS evaluation may be denied if testing is requested solely for CFS without evidence meeting policy medical necessity criteria.
Required clinical documentation and qualified examiner
Testing must be accompanied by a detailed clinical interview and a review of psychological, medical, educational, and other relevant records. Tests should be administered, scored, and interpreted by a qualified examiner (e.g., licensed psychologist, neuropsychologist, or other appropriately credentialed clinician) with expertise in the relevant area.
- Include clinical question(s), prior treatment history, prior medications/psychotherapy attempts (when relevant), and rationale for selected instruments.
- Document examiner credentials and role (e.g., psychologist, technician under supervision) and time units requested.
- Provide copies or summaries of prior evaluations, imaging, or relevant medical records that informed the decision to test.
CNAD documentation expectations
When computerized neuropsychological assessment devices (CNADs) are used (including for MS-related testing), document the specific device/battery, the version, the psychometric evidence supporting its use for the intended purpose, test-retest reliability/validity where available, and whether testing was supervised/administered in a controlled clinical environment.
- Specify device name, version, and modules used (e.g., CogState Brief Battery, CNS-Vital Signs).
- Provide peer-reviewed evidence or vendor validation supporting the CNAD for the proposed indication, and note limitations if the device is considered investigational for that use.
- Document who administered the CNAD (technician vs qualified clinician), testing environment, and scoring/interpretation workflow.
Background
Neuropsychological and psychological tests are standardized instruments administered by qualified clinicians to assess cognitive, behavioral, and personality functioning, assist differential diagnosis between organic and functional disorders, guide rehabilitation and treatment planning, and monitor progression. NPT is commonly used for documented neurologic disease or injury (for example, traumatic brain injury, stroke, epilepsy, hydrocephalus, Alzheimer disease, and AIDS), may require up to 8 hours for administration, scoring, and interpretation, and repeat testing is generally not necessary at intervals of less than 3 months.
Definitions
Revision History
Policy originally became effective.
Policy underwent routine review (last review date recorded).
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