Request for Authorization - Neuropsychological Testing PDF
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This form/policy governs prior authorization and clinical documentation requirements for neuropsychological testing for Highmark BCBS WNY members in Medicaid Managed Care (MMC), HARP, Child Health Plus, and Essential Plan programs. It outlines clinical scenarios where testing may be medically necessary, required supporting clinical information, excluded indications, and the CPT codes to request.
No material clinical or coverage changes
Coverage Summary
This form/policy governs prior authorization and clinical documentation requirements for neuropsychological testing for Highmark BCBS WNY members in Medicaid Managed Care (MMC), HARP, Child Health Plus, and Essential Plan programs. It outlines clinical scenarios where testing may be medically necessary, required supporting clinical information, excluded indications, and the CPT codes to request.
Neuropsychological Testing Authorization Request / Coverage Criteria is CURRENT and applies to neuropsychological testing for members in the specified programs; it requires that testing be related to a known or suspected medical or neurological condition and that results will impact medical treatment planning.
Medical Necessity Criteria
Medically Necessary Criteria
Neuropsychological testing may be considered medically necessary when ALL of the following are met:
ALL of the following
- There is a cognitive or behavioral impairment related to a known or suspected medical or neurological condition
- Testing will impact medical treatment planning
- Testing is used to quantify a cognitive deficit, monitor change, or differentiate cause
- Appropriate clinical assessment and supporting documentation are provided (e.g., clinical interview, psychiatric evaluation, neurologic exam, neuroimaging, EEG, consultations, brief rating scales)
Repeat Testing
Repeat testing is permitted when specific conditions are met:
ANY of the following
- Repeat testing has supporting medical documentation indicating medical necessity (e.g., need to monitor change or re-quantify deficit)
- Routine repeat testing is generally not warranted
Not Medically Necessary / Exclusions
Neuropsychological testing is considered NOT medically necessary when ANY of the following apply:
ANY of the following
- Assessment is solely for behavioral disorders, including ADHD
CPT Codes for Authorization Requests
| 96132 | Neuropsychological testing evaluation services, psychological testing by physician or other qualified healthcare professional, first hour (Base Code listed on form) |
| 96133 | Neuropsychological testing evaluation services, each additional hour (Add-on to 96132) |
| 96136 | Psychological or neuropsychological test administration and scoring, first 30 minutes (Base Code listed on form) |
| 96137 | Psychological or neuropsychological test administration and scoring, each additional 30 minutes (Add-on to 96136) |
| 96138 | Psychological or neuropsychological test interpretation by physician or other qualified healthcare professional, first 30 minutes |
| 96139 | Psychological or neuropsychological test interpretation, each additional 30 minutes (Add-on to 96138) |
| 96132 | Neuropsychological testing evaluation services, psychological testing by physician or other qualified healthcare professional, first hour (Base Code listed on form) |
| 96133 | Neuropsychological testing evaluation services, each additional hour (Add-on to 96132) |
| 96136 | Psychological or neuropsychological test administration and scoring, first 30 minutes (Base Code listed on form) |
| 96137 | Psychological or neuropsychological test administration and scoring, each additional 30 minutes (Add-on to 96136) |
| 96138 | Psychological or neuropsychological test interpretation by physician or other qualified healthcare professional, first 30 minutes |
| 96139 | Psychological or neuropsychological test interpretation, each additional 30 minutes (Add-on to 96138) |
Provider Actions & Authorization Requirements
Include Supporting Clinical Records
Attach relevant medical records and clinical assessments to support the request and rationale for testing, including dates and results when available.
- Clinical interview
- Psychiatric evaluation
- Neurologic exam
- EEG
- Neuroimaging (CT, MRI, PET)
- Consultations (e.g., school, PCP, specialists)
- Prior psychological/neuropsychological testing
Specify ICD-10 Codes and Test Details
Identify the ICD-10-CM diagnosis(es) under evaluation (current or provisional). List the specific neuropsychological tests requested with expected administration time, specify versions or subtests when applicable, and provide the total units and total time requested.
Risk of Denial for Behavioral-Only Indications
Claims or authorization requests for neuropsychological testing that are solely for behavioral disorders, including ADHD, may be considered not medically necessary and are at risk for denial.
Background
Neuropsychological testing evaluates cognitive, motor, and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders. It is intended to quantify deficits, monitor change, and differentiate causes when results will affect medical treatment planning. Testing may be considered medically necessary when there is a cognitive or behavioral impairment related to a known or suspected medical or neurological condition and when testing will impact medical treatment planning.
Required supporting clinical assessment and documentation examples include clinical interview, psychiatric evaluation, neurologic exam, neuroimaging (CT/MRI/PET), EEG, consultations, brief rating scales or inventories, and prior testing results; routine repeat testing is generally not warranted unless there is documentation supporting medical necessity to re-evaluate or monitor change.
Neuropsychological testing: Comprehensive evaluation of cognitive, motor, and behavioral functional abilities related to developmental, degenerative, and acquired brain disorders. It is used to quantify deficits, monitor change, and help differentiate causes when results will affect medical treatment planning.
Revision History
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