CurrentAnthemPolicy N/A

Request for Authorization: Neuropsychological Testing (Indiana)

This document governs prior authorization requests for neuropsychological testing for Anthem members in Indiana programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging, and Medicare Advantage). It describes when testing is considered medically necessary and administrative form fields required for requests.

Policy Summary

PayerAnthem

PolicyNeuropsychological testing authorization (Indiana)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via the Anthem form (preferred electronically via Availity) with listed CPT codes and required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96130-96139CPT codes listed on request form

1 unitSpecific limits noted

IndianaState-specific form use

Not coveredBehavioral disorders excluded

Coverage / Medical Necessity Criteria

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Medical necessity criteria

Covered when ALL of the following are met:

Primary clinical indication: Testing is for cognitive or behavioral impairment related to a known or suspected medical or neurological condition (examples include traumatic brain injury, encephalitis, epilepsy with suspected cognitive impairment, multiple sclerosis with suspected/demonstrated cognitive impairment, anoxic/hypoxic brain injury, cerebrovascular accident/stroke, history of intracranial surgery, cerebral mass, planned neurosurgery for epilepsy control, confirmed neurotoxin exposure including cancer treatments, suspected dementia, Parkinson disease, genetic causes, or hydrocephalus)

Document specific condition and dates on the authorization form

Impact on care: Results are expected to impact medical treatment planning (to quantify a deficit, monitor change over time, or differentiate cause)

Provider must state on the request how test results will change management

Supporting documentation: Provide relevant clinical information and records such as clinical interview, neurologic exam, EEG, psychiatric evaluation, prior psychological/neuropsychological testing results, medication list, substance use history, and other pertinent medical records

Attach dates and specific reports as available

Repeat testing: Routine repeat testing is generally not warranted; repeat testing may be medically necessary only with supporting medical documentation

Document rationale for repeat testing and the interval since prior testing

Neuropsychological testing is not considered medically necessary when performed solely for the assessment of behavioral disorders, including ADHD (attention‑deficit/hyperactivity disorder). Requests for testing for these indications may be denied.

Assessment for behavioral disorders — including ADHD — does not meet medical necessity for neuropsychological testing. Clinical requests should document a medical or neurologic condition and explain how testing results will change medical treatment; behavioral‑only evaluations do not satisfy these requirements.

CPT / Billing Codes

Requested CPT Codes on FormCPT

96130	Neuropsychological testing, short (per form)
96131	Neuropsychological testing, interpretation/report
96136	Psychological or neuropsychological test administration
96137	Psychological or neuropsychological test administration with scoring/interpretation
96138	Psychological or neuropsychological test administration (extended)
96139	Psychological or neuropsychological test interpretation

Units allowed — annotations on request form

Codes annotated 'Only one unit allowed'96130, 96136, 96138 are each annotated on the form as 'Only one unit allowed'

Other CPT codes on form96131, 96137, 96139 appear on the form without the 'Only one unit allowed' annotation

Form requires unit(s) requestedEach listed CPT line includes a field 'Unit(s) requested =' to indicate the number of units requested

Authorization Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for neuropsychological testing. Submit requests using Anthem's preferred electronic submission via Availity (https://availity.com). Paper or fax submissions are accepted but may delay processing; fax numbers for behavioral health outpatient vary by program (see form). Indicate the specific CPT codes and units being requested on the authorization form.

Submit electronically via Availity: https://availity.com (preferred)
If faxing, use the behavioral health outpatient fax numbers on the form: 844-456-2698 (Hoosier Healthwise/Healthy Indiana Plan/Hoosier Care Connect), 844-430-1703 (Medicare Advantage), 877-410-0623 (Indiana PathWays for Aging)
Include the CPT test codes and units: 96130 (only one unit allowed), 96131, 96136 (only one unit allowed), 96137, 96138 (only one unit allowed), 96139 — list units requested and total time
Complete provider and billing information on the form (provider name, NPI, Tax ID, servicing address, telehealth vs in-person)

Documentation Required

Provider Action — Complete Clinical Info

Providers: use the Anthem authorization form to supply clear clinical rationale and attach supporting medical records. Include dates and relevant history (e.g., dates of TBI, encephalitis, stroke, anoxic injury, intracranial surgery, seizures, multiple sclerosis, hydrocephalus, cerebral mass) and prior test results when applicable.

List the specific neuropsychological tests to be administered and expected administration time; indicate if selected subtests only
State how test results will impact treatment planning and management
If telehealth, mark services being rendered via telehealth on the form

Documentation Required

Submit Supporting Clinical Records

Required clinical documentation must be submitted with the authorization request. Provide pertinent history, relevant medical records, medication list, substance use history, prior psychological/neuropsychological testing (dates and results), and documentation supporting the indication for testing.

Include history and dates for conditions such as: traumatic brain injury, encephalitis, epilepsy, multiple sclerosis, anoxic/hypoxic injury, cerebrovascular accident (CVA/stroke), intracranial surgery, cerebral mass, genetic conditions, hydrocephalus
Provide prior test reports and the rationale for repeat testing if applicable
List current medications and indicate whether alcohol/illicit substance effects have been ruled out as a cause of cognitive impairment

Denial Risk

Exclusion — Behavioral Disorder Testing

Neuropsychological testing is NOT considered medically necessary for assessing primary behavioral disorders, including ADHD. Do not submit requests for testing when the sole indication is behavioral disorder evaluation without an associated medical or neurologic condition.

Requests for testing for behavioral disorders (e.g., ADHD) will be denied as not medically necessary unless there is a documented medical/neurologic condition requiring cognitive assessment

Background / Rationale

Neuropsychological testing is a comprehensive evaluation of cognitive, motor, and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders. Testing may be considered medically necessary when there is cognitive or behavioral impairment related to a known or suspected medical or neurologic condition and when the results are expected to impact medical treatment planning (for example, to quantify deficits, monitor change, or differentiate cause). Routine repeat testing is generally not warranted and repeat testing may be medically necessary only with supporting medical documentation.

OpenPayer

Request for Authorization: Neuropsychological Testing (Indiana)

Coverage / Medical Necessity Criteria

CPT / Billing Codes

Authorization Submission & Documentation Requirements

Background / Rationale

Key Definitions

Test Modalities / Service Types

Visit / Unit Limits