CurrentKaiser PermanentePolicy N/A

Psychological and Neuropsychological Testing

Clinical review criteria governing when psychological and neuropsychological testing are considered medically necessary for Kaiser Foundation Health Plan of Washington members; applies to providers submitting requests for these services.

Policy Summary

PayerKaiser Permanente

PolicyPsychological and Neuropsychological Testing

Policy CodePolicy N/A

Change TypeRevised - consolidated criteria

Effective DateN/A

Next Review DateN/A

Key ActionObtain pre-authorization for listed psychological and neuropsychological testing CPT codes and submit the last 6 months of PCP or specialty notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Merged Neuropsychological Testing and Psychological Testing criteria.

96116-96146, 90791CPT codes listed for testing services

6 monthsSupporting documentation required

MCG-basedMedical necessity criteria source

WAApplicable plans

Coverage and Medical Necessity Criteria

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Medical necessity indications

Covered when the following indication-specific criteria are met:

Psychological testing indications: Any of: differential diagnosis when interview/observation insufficient; develop treatment recommendations after trials of medications and/or psychotherapy without adequate progress; recent mild traumatic brain injury (concussion) screening early after injury to assess cognitive/emotional functioning and return-to-activity decisions; majority of pre-surgical evaluations (spinal cord stimulator, complex spine, bariatric surgery); recent or non-complex memory change (<=6 months) needing clarification of extent and impact on functioning.

Source: psychological testing section

Neuropsychological testing indications: Any of: known neurological disease or condition (e.g., dementia, CVA, TBI, multiple sclerosis, Parkinson's) where testing is needed to determine impact on brain functioning and ability to function; presence of significant cognitive deficit, mental status abnormality, behavioral change, or memory loss requiring quantification, monitoring, diagnostic clarification, or cause differentiation (organic vs psychiatric); medically complex or not well understood cases with prominent memory/cognitive deficits; persistent cognitive symptoms after prior negative or non-contributory workups (e.g., neurology consult, imaging, MMSE, prior clinical psychological evaluation); pre- and post-procedure evaluation for deep brain stimulation for Parkinson's disease.Do not refer mild TBI patients prior to 3 months post-injury

Source: neuropsychological testing section

Neuropsychological testing is subject to member contract provisions and will not be authorized for any exclusions found in the member's contract. Providers should consult the member's Evidence of Coverage or plan documents for specific exclusions (for example, learning disabilities) before requesting authorization.

Referral for neuropsychological testing for patients with mild traumatic brain injury (TBI) is discouraged prior to 3 months post-injury, because the majority of mild TBI patients recover essentially back to baseline during the initial 3-month period. Consider delaying testing until after this interval unless there are atypical features or clear clinical indications for earlier evaluation.

Billing and Code Lists

Neuropsychological testing CPT codesCPTCovered

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]) , by physician or other qualified health care professional, both face-to-face time.
96121	Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]) , 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).
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).
96133	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; each additional hour (List separately_in addition to code for primary procedure).
96136	Psychological or neuropsychological test administration and scoring by physician/other qualified health care professional, two or more tests, any method; first 30 minutes.
96137	Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes (List separately_in addition to code for primary_procedure).
96138	Psychological or neuropsychological test administration and scoring by technician, two or more tests_any method; first 30 minutes.
96139	Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure).

Psychological testing and related CPT codesCPTCovered

96146	Psychological or neuropsychological test administration, with single automated, standardized instrument; automated result only.
90791	Psychiatric diagnostic evaluation.
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; first hour.
96131	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 separately_in addition to code for primary procedure).

inv-06: Mild TBI referral timing

Timing restrictionDo not refer patients with mild traumatic brain injury (mild TBI) for neuropsychological testing prior to 3 months post‑injury because the majority recover to baseline during that period.

RationaleMost mild TBI patients recover essentially back to baseline over the initial 3 months post‑injury, so early testing is discouraged.

Exception contextIf cognitive symptoms persist beyond 3 months or there are other indications (e.g., known neurologic disease, significant deficit), neuropsychological testing may be indicated after the 3‑month period.

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Authorization is required per plan rules for psychological and neuropsychological testing codes listed when criteria in this policy are met.

Affected codes include but may not be limited to: 90791, 96116, 96121, 96130-96139, 96146. To verify specific authorization requirements by plan type, use the Pre-authorization Code Check.

Step Therapy

Therapy Prior to Testing

For psychological testing, testing is indicated after trials of medications and/or psychotherapy without adequate progress. Psychological testing is used to develop treatment recommendations when the member has been tried on various medications and/or psychotherapy and continues to be symptomatic, for differential diagnosis when interview/observation cannot resolve diagnostic questions, for recent mild traumatic brain injury screening, pre-surgical evaluations, or when there has been a recent change in memory.

Documentation Required

Required Clinical Documentation

Submit the last 6 months of PCP or specialty notes that describe the member's cognitive deficits to support medical necessity. Include documentation of trials of medications and/or psychotherapy, relevant history, symptom chronology (including any change in memory within the past six months), and any prior assessments or screening results.

Denial Risk

Documentation Insufficiency

Insufficient documentation—such as absence of the last 6 months of PCP or specialty notes, lack of documentation of prior treatment trials, or missing clinical detail about cognitive deficits—may lead to denial or delayed authorization.

Clinical Background

Psychological tests assess a range of mental abilities and attributes—including personality, cognition, behavior, and emotional functioning—and are used for differential diagnosis, treatment planning, and other clinical decisions. Neuropsychological testing is a more comprehensive, in-depth neuro-diagnostic evaluation focused on brain–behavior relationships that quantifies cognitive strengths and limitations across multiple domains (e.g., attention, memory, language, visuospatial skills, reasoning, executive function, and motor/perceptual abilities). It is indicated when there is known neurologic disease, significant or complex cognitive deficits, persistent unexplained cognitive symptoms after prior workups, or when detailed quantification of cognitive function is needed to guide management.

Definitions

inv-12: Psychological testing definition and indications

DefinitionPsychological testing assesses a range of mental abilities and attributes including achievement, personality, cognitive and behavioral functioning; it includes basic assessment of memory and intellectual functioning.

Indication — treatment planningDevelop treatment recommendations after trials of medications and/or psychotherapy without adequate progress when results will influence treatment planning.

Indication — differential diagnosisDifferential diagnosis when history and symptoms are not attributable to a single psychiatric diagnosis and cannot be resolved by interview, observation, or level‑of‑care assessment.

Indication — recent mild TBI screeningScreening of cognitive status soon after a recent mild traumatic brain injury (concussion) when immediate questions about cognitive and emotional functioning or return to activities are needed.

Indication — pre‑surgical evaluationsMajority of pre‑surgical evaluations (e.g., spinal cord stimulator, complex spine, bariatric surgery).

Indication — recent/non‑complex memory changeRecent change in memory (within past 6 months) or non‑complex memory complaints where testing can clarify extent and impact on functioning.

inv-13: Neuropsychological testing definition and indications

DefinitionNeuropsychological testing is a sub‑classification of psychological testing: a comprehensive, in‑depth neuro‑diagnostic evaluation assessing multiple cognitive domains to identify cognitive strengths and limitations and brain–behavior relationships.

Indication — known neurologic diseasePresence of a known neurological disease or condition (e.g., dementia, CVA, traumatic brain injury, multiple sclerosis, Parkinson's) when testing is needed to determine impact on brain functioning and patient ability to function.

Indication — significant cognitive deficitSignificant cognitive deficit, mental status abnormality, behavioral change, or memory loss requiring quantification, monitoring, diagnostic clarification or differentiation of cause (organic vs psychiatric).

Indication — persistent unexplained symptomsMedically complex or not well understood cases with persistent cognitive symptoms after prior workups (e.g., neurology consult, imaging, MMSE, prior psychological evaluation) that were negative or non‑contributory.

Indication — procedural evaluationAs part of pre‑ and post‑procedure evaluation for deep brain stimulation for Parkinson's disease.

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