CurrentFidelis CarePolicy FCBH.301.01

Neuropsychological, Psychological, and Developmental Testing

This policy governs Fidelis Care coverage and medical necessity review for neuropsychological, psychological, and developmental testing services for members; it describes indications, required provider qualifications, limits, and codes used for authorization and reimbursement. It affects providers requesting or performing these testing services for Fidelis Care members.

Policy Summary

PayerFidelis Care

PolicyNeuropsychological, Psychological, and Developmental Testing

Policy CodePolicy FCBH.301.01

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain and document prior psychiatric/psychological evaluation and other assessments showing unanswered diagnostic questions before requesting authorization for testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 8 hrsstandard battery time

12 monthsrepeat testing interval

ICD/CPT listcodes listed

licensed psychologistqualified provider required

Coverage and Medical Necessity Criteria

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Medically Necessary Criteria

Covered when ALL of the following are met:

Overall medical necessity: Testing is authorized to advance medical management related to diagnosis, prognosis, or treatment only after prior psychiatric or psychological evaluation, observation in therapy, diagnostic testing, imaging (e.g., MRI/CT), medical or neurological evaluations, and consultations have not provided the needed information or leave diagnostic question(s) unanswered that testing could address.

Indications for testing

a: Assessment of neurocognitive abilities for clinical conditions such as traumatic brain injury, stroke, neurosurgery, or medical diagnoses affecting the CNS (e.g., epilepsy, hydrocephalus, AIDS, brain tumor, cerebral anoxic/hypoxic episode, CNS infection, neoplasm or vascular injury, neurodegenerative or demyelinating disorders, extrapyramidal disease, or metabolic encephalopathy after stabilization and removal of offending agents).
b: Evaluation and diagnosis of dyslexia.
c: Pre‑surgical evaluation when the patient is being considered for epilepsy surgery.
d: Differential diagnosis between psychogenic and neurogenic syndromes when combined with clinical, laboratory, and imaging data and when this information may assist in determining a diagnosis.
e: Assessment to assist development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders.
f: Quantification of the patient's deficits when the information will be useful in determining prognosis.
g: Monitoring progression of cognitive impairment secondary to neurological disorders.

Test selection and battery principles: Each test administered must be individually medically necessary; tests administered should be the fewest necessary to answer the unanswered question(s); a standard battery is only medically necessary if each test contributes unique information.

Patient ability to participate: Patient must be able to reasonably participate in the testing process (appropriate mental status, intellectual abilities, and language skills).

Provider qualifications for neuropsychological testing: Neuropsychological testing requires a licensed psychologist who specializes in neuropsychological testing and is board certified or has completed a post‑doctoral fellowship in neuropsychology.

Time standards: National standards for a standard neuropsychological or psychological battery are up to 8 hours (including scoring, interpretation, report writing, and feedback); some conditions may require more time (e.g., very young children being assessed for autism, individuals with dementia or brain injury, or speech/language impairments).

Neuropsychological, psychological, and developmental testing performed solely as screening tools for individuals or general populations is excluded from coverage. This includes testing when abnormalities are not suspected, testing done for educational or vocational purposes that do not support medical management (for example, routine school placement, accommodations, IQ, or achievement testing), and testing performed merely for member convenience. An exception is testing specifically for the evaluation and diagnosis of dyslexia, which is not excluded.

Testing is not covered if administered while the patient is currently intoxicated, or within 10 days post-detox. Coverage is also excluded when the patient has prior substance-related brain dysfunction and there is no expectation that testing will change medical management or provide new information to influence diagnosis or treatment decisions.

Tests conducted by individuals who are not appropriately qualified risk denial. Neuropsychological testing must be performed by a licensed psychologist who is board certified or has completed a post-doctoral fellowship in neuropsychology. Testing is also not covered when the patient cannot meaningfully participate due to cognitive or neurological impairment. Routine screening, non-medical testing, or repeat testing within 12 months without evidence of clinical change (except for developmental testing where periodic reassessment is reasonable) are considered not medically necessary.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization and Affected Codes

Prior authorization required for neuropsychological, psychological, and developmental testing when medically necessary criteria are met. Testing is authorized only after prior psychiatric/psychological evaluations, observations, diagnostic testing (e.g., MRI, CT), or medical/neurological evaluations and consultations have not provided the needed information or remain unclear and there are diagnostic questions testing could answer.

Affected CPT codes include: 96112, 96113, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146
Prior evaluation documentation (psychiatric/psychological evaluations, therapy observations, imaging, medical/neurological consults) must accompany authorization requests

Denial Risk

Non-medical Indications — Not Covered

Testing performed for non-medical indications is not covered. Examples include population screening, general screening tests, educational or vocational testing for school placement or accommodations (except dyslexia evaluation), IQ and achievement testing when not tied to medical management, and testing performed solely for member convenience.

Not covered: screening tests for individuals or general populations
Not covered: testing for educational or vocational purposes (school placement, accommodations), except dyslexia evaluation
Not covered: testing performed for convenience without relationship to medical management

Denial Risk

Qualified Provider Requirements

Testing performed by providers without appropriate qualifications may be denied. Neuropsychological testing must be performed by a licensed psychologist who specializes in neuropsychological testing and is board-certified or has completed a post-doctoral fellowship in neuropsychology. Psychological and developmental testing should be performed by qualified healthcare professionals per scope of practice.

Neuropsychological testing: licensed psychologist with neuropsychology specialization and board certification or post-doctoral fellowship
Testing by unqualified providers is a denial risk

Documentation Required

Supporting Clinical Documentation

Supporting clinical documentation must be provided with the authorization and medical record: prior psychiatric or psychological evaluations, therapy observations, relevant imaging (MRI, CT), and medical/neurological workup or consultations. Documentation should demonstrate that prior assessments did not answer the clinical question and that testing will inform diagnosis, prognosis, treatment, or rehabilitation planning.

Include prior psychiatric/psychological evaluations and observations in therapy
Include relevant imaging and diagnostic test results (e.g., MRI, CT)
Include medical and neurological evaluations/consultation notes showing unanswered clinical questions

Billing Rule

Coding, Time Documentation, and Individual Test Necessity

Coding and time documentation must identify which tests were administered, time units for administration/scoring/interpretation, and ensure billed codes match CPT descriptions (first unit and additional unit rules). Each administered test must be individually medically necessary; a battery is only allowed if each test contributes unique information.

Document tests administered and the clinical reason each is necessary
Match billed CPT codes to service performed and time (e.g., 96112/96113 developmental testing first 60 / additional 30 minutes; 96116/96121 neurobehavioral status exam first 60 / additional 60 minutes; 96130/96131 psychological testing evaluation first/each additional hour; 96136/96137 test administration first/each additional 30 minutes; 96138/96139 technician administration; 96146 computerized testing per 15 minutes)
Report time spent on administration, scoring, interpretation, report writing, and feedback as applicable

CPT Codes and Billing Categories

Developmental and Neurobehavioral CPT CodesCPTCovered

96112	Developmental test administration, physician or other qualified health care professional; first 60 minutes
96113	Developmental test administration, physician or other qualified health care professional; additional 30 minutes
96116	Neurobehavioral status exam, physician or other qualified health care professional; first 60 minutes

Neurobehavioral and Psychological Evaluation CPT CodesCPTCovered

96121	Neurobehavioral status exam; additional 60 minutes
96130	Psychological testing evaluation services, including integration, interpretation, treatment planning, report and interactive feedback; first 60 minutes
96131	Psychological testing evaluation services; additional 60 minutes
96132	Neuropsychological testing evaluation services; first hour
96133	Neuropsychological testing evaluation services; each additional hour
96136	Test administration and scoring by physician or qualified health care professional, two or more tests, first 30 minutes
96137	Test administration and scoring by physician or qualified health care professional, two or more tests, each additional 30 minutes

Technician and Computerized Testing CPT CodesCPTCovered

96138	Test administration and scoring by technician, two or more tests, first 30 minutes
96139	Test administration and scoring by technician, two or more tests, additional 30 minutes
96146	Computerized testing with automated result only, per 15 minutes

Definitions of Testing Types

Neuropsychological testing — definition and role

PurposeAssesses aspects of brain functioning, brain damage, or brain disease to inform diagnosis, prognosis, treatment planning, localization of disease, and to track recovery.

Clinical usesDifferentiate organic (e.g., brain damage, neurological dysfunction or degeneration) versus functional psychiatric disorders and assist in development of focused treatment plans for complex cases.

When authorizedUsed to address specific diagnostic questions that cannot be answered by standard clinical interview/evaluation and to advance medical management.

Role in careHelps quantify deficits for prognosis and to monitor response to treatment and recovery over time.

Psychological testing — definition and role

PurposeEvaluates intellectual strengths and weaknesses, psychopathology, mental health risk, insight, motivation, and interpersonal functioning.

Clinical valueFacilitates accurate diagnoses in complicated or complex clinical cases and aids development of focused treatment plans.

ScopeActs as a specialty tool to assess challenging, recalcitrant, or complex presentations not fully resolved by standard evaluation.

ApplicationUsed when psychological testing can answer specific diagnostic questions to inform treatment and management decisions.

Developmental testing — definition and role

PurposeAssesses a child’s motoric, language, speech, cognitive, perceptual, social, and interpersonal performance relative to same-aged peers.

Clinical goalDifferentiates normal from abnormal development to guide medical decisions, including referrals for specialist assessment.

Use contextPerformed when developmental assessment is necessary to answer specific diagnostic or management questions beyond routine evaluation.

PopulationChildren whose developmental progress is in question across multiple domains (motor, language, cognition, social, perception).

OpenPayer

Neuropsychological, Psychological, and Developmental Testing

Coverage and Medical Necessity Criteria

Provider Requirements, Authorization, and Documentation

CPT Codes and Billing Categories

Definitions of Testing Types

Background and Purpose