CurrentlucetPolicy 20.5.004

Psychological and Neuropsychological Testing Criteria - 2024

Defines authorization parameters and medical necessity criteria for psychological and neuropsychological testing for Lucet members for plan year 2024, including requirements for test administration, provider qualifications, and documentation for initial authorization.

Policy Summary

Payerlucet

PolicyPsychological and Neuropsychological Testing Criteria - 2024

Policy CodePolicy 20.5.004

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionInitial authorization requires documentation that ALL Initial Authorization Request criteria are met, including a completed face-to-face diagnostic assessment and a comprehensive post-testing report.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes have been made to the policy.

8Initial Authorization Criteria

2Expectation of Care Delivery Items

Coverage Summary

This policy defines authorization parameters and medical necessity criteria for Psychological and Neuropsychological Testing for Lucet members for plan year 2024. It requires documentation of initial assessment, appropriate test selection and administration, qualified provider oversight, and comprehensive reporting to support benefit approval. (Policy number: 20.5.004; Effective date: 2023-01-01; Last review: 2023-09-01.)

Medical Necessity Criteria

Initial Authorization Request

Must meet all of the following:

ALL of the following

An initial face-to-face complete diagnostic assessment has been completed.
The proposed battery of tests is individualized to meet the member's needs and to answer the specific diagnostic/clinical questions identified by the diagnostic assessment.
The proposed battery of tests is standardized and has nationally accepted validity and reliability.
Testing is administered and interpreted by a licensed psychologist or other qualified mental health provider (as defined by applicable State and Federal law and scope of practice). Technician-administered and/or computer-assisted testing may be allowed under the direct supervision of a licensed psychologist or other qualified mental health provider. Neuropsychological testing must be supervised and interpreted by a licensed psychologist with specialization in neuropsychology.
The requested tests must have normative data and suitability for use with the member's age group, culture, primary language, and developmental level.
At the completion of the testing, a comprehensive report is generated that includes the tests used, scores, and an in-depth summary of the findings of the assessment.
The member is capable of participating in the selected battery of tests.
The results of the proposed testing can reasonably be expected to contribute to the development and implementation of an individualized treatment plan.

Expectations of Care Delivery

ALL of the following

The requested time for administration, scoring and interpretation of the proposed testing battery must be consistent with the time requirements indicated by the test publisher.
The qualified health professional responsible for the development of the test battery will adhere to CPT code definitions for screening tests, psychological tests, neuropsychological tests, use of technicians, and machine-administered tests.

Provider Actions

Prior Authorization

Authorization requirement

Initial authorization requires documentation that ALL criteria in the Initial Authorization Request are met, including a completed face-to-face diagnostic assessment and a comprehensive post-testing report.

Documentation Required

Comprehensive report required

At the completion of testing providers must supply a comprehensive report that includes the tests used, scores, and an in-depth summary of the findings to support benefit approval.

Documentation Required

Provider qualifications and supervision

Testing must be administered and interpreted by a licensed psychologist or other qualified mental health provider per applicable law and scope of practice. Technician-administered and computer-assisted testing are allowed only under the direct supervision of a licensed psychologist or other qualified provider. Neuropsychological testing must be supervised and interpreted by a licensed psychologist with specialization in neuropsychology.

Denial Risk

Denial risk for inappropriate tests or insufficient justification

Requests may be denied when the proposed tests are not standardized or lack nationally accepted validity/reliability, are not appropriate for the member’s age, culture, primary language, or developmental level, when the member is not capable of participating in the selected battery, or when results are unlikely to contribute to an individualized treatment plan.