DraftOptumPolicy BH803PNTSCC0102025

Supplemental Clinical Criteria: Psychological and Neuropsychological Testing

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Supplemental clinical criteria governing provider qualifications, coverage rationale, limitations, and developmental/automated testing guidance for psychological and neuropsychological testing for behavioral health benefit plans managed by Optum; applies to reviewers and providers when determining coverage and prior authorization. Does not apply to Department of Managed Health Care-regulated Commercial Health Plans in California.

Policy Summary

PayerOptum

PolicySupplemental Clinical Criteria: Psychological and Neuropsychological Testing

Policy CodePolicy BH803PNTSCC0102025

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 21, 2025

Next Review DateOct 21, 2025

Key ActionConfirm member eligibility, member-specific benefits, and provider qualifications before requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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DraftOptumPolicy BH803PNTSCC0102025

Supplemental Clinical Criteria: Psychological and Neuropsychological Testing

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Policy Summary

PayerOptum

PolicySupplemental Clinical Criteria: Psychological and Neuropsychological Testing

Policy CodePolicy BH803PNTSCC0102025

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 21, 2025

Next Review DateOct 21, 2025

Key ActionConfirm member eligibility, member-specific benefits, and provider qualifications before requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Automated testingAutomated testing guidance

NMN usesNot medically necessary uses listed

Tele-assessment not coveredTele-assessment stance

96105/96125/96110-13/96127Codes noted

Multiple studiesEvidence citations

Coverage Criteria — When Testing Is (Not) Covered

inv-01: Not medically necessary — specified uses

Neuropsychological testing is considered unproven and not medically necessary for the following specific uses:

Not medically necessary list: Baseline neuropsychological testing in asymptomatic persons at risk for sport-related concussions; computerized neuropsychological testing when used alone for evaluating concussions; neuropsychological testing for the following diagnoses alone without other covered conditions: headaches (including migraine), history of myocardial infarction, and intermittent explosive disorder; computerized cognitive testing products such as Mindstreams® Cognitive Health Assessment and QbTest.

These uses are explicitly listed as unproven and not medically necessary in the policy.

inv-02: Tele-assessment coverage criteria

Tele-assessment coverage and exceptions

Tele-assessment general rule: Tele-assessment is typically not covered unless required by regulation or contract and unless case-specific criteria are met.

Consult member-specific benefit plan documents and applicable mandates.

Situations where tele-assessment may be considered: Exceptions may be made to extend reach to isolated populations, areas lacking providers, or to reduce number of clinic visits when face-to-face assessment is not reasonably available.

Examples include geographic isolation or lack of available qualified providers.

Conditions that must be satisfied for tele-assessment to be covered: Provider must be licensed/credentialed in the member's state; provider must be proficient in telehealth delivery; a HIPAA-compliant platform must be used; test materials must be secured; adequate audio-visual monitoring of test administration must occur; the member must be an appropriate candidate with necessary technology access and literacy; informed consent for telehealth testing must be obtained; and test selection/administration must preserve validity and reliability without modifications that would undermine scores.

All listed safeguards and competency requirements must be satisfied for coverage.

inv-03: Non-behavioral benefit testing

Services not typically covered under the behavioral health benefit

Non-behavioral benefit assessments: Assessment of aphasia (96105); standardized cognitive performance testing (96125); developmental testing (96110, 96112, 96113); and brief emotional/behavioral assessment (96127) are not considered psychological or neuropsychological testing for behavioral health and are usually managed under medical benefits unless the member's contract specifically requires behavioral health coverage.

Codes and descriptions are listed in the policy as typically not covered under behavioral health.

This Supplemental Clinical Criteria does not apply to Department of Managed Health Care–regulated commercial health plans in California. Reviewers and providers must therefore follow any superseding California-specific rules and the member's specific benefit plan when making coverage and authorization determinations for those plans.

Face-to-face assessment is the standard of care for psychological and neuropsychological testing. Tele-assessment is typically not covered unless required by regulation or contract and only when case-specific criteria are met (for example, to reach isolated populations or when no qualified local providers are available).

Tele-assessment may be considered only if all required conditions are satisfied: the provider is licensed/credentialed in the member's state and proficient in telehealth delivery; a HIPAA-compliant telehealth platform is used; test materials are secured; adequate audio-visual monitoring of test administration will occur; the member is an appropriate candidate with access to and literacy for the required technology; informed consent for telehealth testing has been obtained; and the selected tests can be administered remotely without undermining validity or reliability.

Computerized or automated neuropsychological tests have limited applications within this coverage guideline. Specifically, computerized neuropsychological testing when used alone for evaluating concussions is considered unproven and not medically necessary. Certain commercial products (for example, Mindstreams® Cognitive Health Assessment and QbTest) are explicitly listed as not medically necessary when used in isolation.

Evidence summarized in the document indicates variable validity and limited impact on long-term clinical outcomes for computerized cognitive testing; some studies of continuous performance tests (e.g., QbTest) show limited ability to distinguish ADHD from other psychiatric conditions, underscoring the limitation of relying on computerized tests alone for diagnostic decisions.

Tele-assessment is not medically necessary when remote delivery would require modifications that undermine test validity, reliability, security, or adequate monitoring. Examples include situations where standard administration procedures must be modified to such an extent that test score reliability or validity is compromised, or where essential tests cannot be administered remotely.

Tele-assessment is also not appropriate when member or provider circumstances prevent reliable remote administration: the provider is not licensed or credentialed in the member's state, is not sufficiently proficient in telehealth, a HIPAA-compliant platform will not be used, test materials cannot be secured, adequate audio-visual monitoring is not possible, the member lacks technology access or literacy, the member is not a suitable candidate due to age/condition/environment, or informed consent for telehealth testing has not been obtained.

Coding — CPT and Related Codes

Codes noted as not typically behavioral health covered or as brief/developmental assessmentsCPT

96105	Assessment of Aphasia
96125	Standardized cognitive performance testing (OT assessment)
96110	Developmental testing
96112	Developmental testing
96113	Developmental testing
96127	Brief emotional/behavioral assessment

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization: verify eligibility, benefits, and regulatory requirements

Confirm member eligibility, member-specific benefit coverage, and any federal/state regulatory requirements that supersede the member's benefits prior to authorization. Have provider qualification documentation and rationale for selected tests available to support prior authorization decisions.

Verify member eligibility and the member-specific benefit plan before applying these criteria.
Identify and follow any superseding federal or state mandates that override member benefits.
Make provider licensure/training documentation and test selection rationale available to the reviewer.

Prior Authorization

Tele-assessment prior authorization: consult member plan and mandates

Tele-assessment is generally not authorized unless required by regulation or contract; consult the member-specific benefit plan and applicable mandates to determine whether remote testing may be authorized.

Key Definitions

Psychological Test Evaluation Services — scope and components

DefinitionPsychological Test Evaluation Services: formal procedures using reliable, validated tests to measure intellectual, cognitive, emotional, and behavioral functioning and to identify psychopathology, personality, interpersonal processes, and adaptive skills.

Scope of activitiesIncludes test selection, review of records, consultation with referral source, integration of clinical data, clinical decision-making, report preparation, and reviewing results with member and/or caregivers.

Administration and scoringAdministration and scoring performed according to standardized test manual instructions by a doctoral-level psychologist or qualified masters-level provider.

Provider qualificationsProviders must have appropriate licensure/training (doctoral-level psychologist licensed to practice independently or masters-degreed behavioral health professional whose licensure allows psychological testing).

Professional standardsServices must be conducted in accordance with professional and ethical standards for psychological testing.

Automated / Computerized Testing — Role and Limits

inv-23: Automated/computerized cognitive testing — single top-level node summarizing scope and status

Automated/computerized cognitive testing — scope and summary of policy stance

Automated/computerized testing considerations: Automated or app-based tests are primarily screening or surveillance tools that automate administration, scoring and interpretation; they may be useful for screening or estimating change over time and can increase efficiency of assessment pathways (for example, QbTest increased speed of diagnostic decision-making in one study), but overall the evidence base is variable, many digital tests have limited validation compared with traditional multi-domain neuropsychological batteries, and specific computerized products (e.g., Mindstreams®, QbTest) are identified elsewhere in the policy as having insufficient evidence to be considered medically necessary when used alone for certain indications.

Summarizes the document's assessment of automated testing utility and limitations.

Background and Evidence Summary

Psychological and neuropsychological testing are formal, structured procedures that use reliable and validated instruments to measure intellectual, cognitive, emotional, and behavioral functioning and to identify brain dysfunction or psychopathology. These services include test selection, review of records, administration/scoring, integration of clinical data, interpretation, report preparation, and feedback to the member or caregiver.

Neuropsychological testing focuses specifically on identifying brain injury, damage, or dysfunction and the associated functional deficits and typically requires specialized test batteries and interpretation by appropriately trained providers.

Automated or computerized testing can serve as a screening tool or to estimate change over time, but its use is limited by variable sensitivity and validity across instruments and contexts. Such tools should not replace full psychological or neuropsychological assessment when definitive diagnostic information is required.

Policy Summary

PayerOptum

PolicySupplemental Clinical Criteria: Psychological and Neuropsychological Testing

Policy CodePolicy BH803PNTSCC0102025

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 21, 2025

Next Review DateOct 21, 2025

Key ActionConfirm member eligibility, member-specific benefits, and provider qualifications before requesting prior authorization.

SourceLink

On This Page

Check member-specific benefit plan documents and any federal/state mandates before authorizing tele-assessment.

Recognize that face-to-face assessment is the standard of care; exceptions are case-by-case (e.g., provider shortages, geographic isolation).

Note

Include referral rationale, test selection, and provider qualifications with requests

Provide documentation to support any request: include the clinical referral question, test selection rationale, and evidence of provider qualifications specific to the requested tests.

Include the clinical reason for testing and why selected instruments are necessary to answer the referral question.
Attach documentation of provider training/licensure appropriate to the test type.

Step Therapy

Triage: use brief screening (96127) for detection/monitoring, not definitive diagnosis

Use brief screening (96127) for detection, monitoring, or to inform referrals; do not use 96127 as a definitive diagnostic test — it should not substitute for comprehensive psychological or neuropsychological testing.

96127 may inform the decision to refer for formal testing but is not considered definitive diagnostic testing.
Brief screening services are typically managed under medical benefits, not behavioral health, unless contractually required.

Documentation Required

Document provider qualifications and supervision for testing

Document provider licensure, training, and supervision consistent with the test type: doctoral-level psychologists or appropriately credentialed psychiatrists for neuropsychological testing; psychometrists must be supervised with the supervising psychologist providing intake and feedback, final interpretation, report writing, and signature.

Doctoral-level psychologists must be licensed to practice independently and demonstrate sufficient training/experience.
Credentialed psychiatrists must meet listed board accreditation, state licensure, and documented expertise for neuropsychological testing.
Psychometrists administer/score under supervision; supervising psychologist must have face-to-face contact at intake and feedback and is responsible for final interpretation and signature.

Documentation Required

Tele-assessment documentation and safeguards: platforms, materials, monitoring, licensure, consent

For tele-assessment, document use of a HIPAA-compliant platform, measures to secure test materials, evidence of audiovisual monitoring, appropriate state licensure/credentialing, and documented informed consent describing risks and limitations.

Use a HIPAA-compliant telehealth platform and document the platform used.
Document how test materials will be secured and how audio-visual monitoring of administration will occur.
Confirm and document that the provider is licensed/credentialed in the state where the member receives testing.
Obtain and document informed consent that plainly communicates risks and limitations of remote assessment.

Denial Risk

Denial triggers: evaluate against member benefits and listed not-medically-necessary uses

Evaluate requests against the member's benefits and any applicable mandates; services that are limited, excluded, or defined differently by the member's benefit may be denied, including certain computerized testing uses explicitly listed as not medically necessary.

Denials may result when the requested service is limited or excluded by the member's benefit.
Computerized neuropsychological testing used alone for evaluating concussions and baseline testing in asymptomatic persons at risk for sport-related concussions are listed as not medically necessary and may be denied.

Denial Risk

Tele-assessment denial triggers: availability, proficiency, licensure, security, validity, consent

Tele-assessment may be denied when in-person testing is available; when the provider lacks telehealth proficiency or state licensure/credentialing; when a HIPAA-compliant platform, secured materials, or adequate audio-visual monitoring are not used; when the member is not an appropriate candidate or lacks technology access; when tests cannot be administered remotely without undermining validity; or when informed consent for telehealth testing has not been obtained.

Not covered if in-person testing is available.
Not covered if provider is not proficient in telehealth or not licensed/credentialed in the member's state.
Not covered if HIPAA-compliant platform will not be used or test materials cannot be secured.
Not covered if adequate audiovisual monitoring will not occur or the member lacks access/technology literacy.
Not covered if required tests cannot be remotely administered or standard procedures would need modification that undermines validity.
Not covered if informed consent for telehealth testing has not been secured and risks/limitations not communicated.

Neuropsychological Test Evaluation Services — focus and components

DefinitionNeuropsychological Test Evaluation Services: formal procedures using reliable, valid tests specifically focused on identifying brain damage, injury, or dysfunction and associated functional deficits.

Provider qualificationsTypically performed by a doctoral-level psychologist; may involve a credentialed psychiatrist meeting specified neurology/neuropsychiatry certification and state medical licensure requirements.

Supervision and teamPhysician and supervised psychometrician(s) must adhere to national professional and ethical standards for test administration, scoring, and interpretation.

Automated Testing and Result — single fully automated instruments

DefinitionAutomated Testing and Result: single, fully automated instrument for screening or surveillance that automates administration, scoring, and interpretation.

Primary usePrimarily used for screening potentially clinically significant intellectual, cognitive, emotional, and behavioral symptoms or functional deficits.

Longitudinal useMay be used to estimate changes over time for objective progress measurement or periodic surveillance of known risk issues.

Provider scopeAdministration, scoring, and interpretation must be within provider's licensure/training (doctoral psychologist, qualified masters-level provider, or credentialed psychiatrist where applicable).

Brief emotional/behavioral assessment (96127) — scope and limits

DefinitionBrief emotional/behavioral assessment (CPT 96127): a short self-report screening tool used for early detection, monitoring progress, or tracking symptom changes over time.

PurposeUsed in primary care for early detection or to inform decisions about referral for further psychological or neuropsychological testing.

LimitationsNot considered definitive psychological or neuropsychological testing and should not be used for making definitive diagnostic decisions.

Benefit managementTypically managed under medical benefits rather than behavioral health; not usually included on behavioral contracts or fee schedules.

Assessment of Aphasia (96105) — scope and coverage

DefinitionAssessment of Aphasia (CPT 96105): evaluation of expressive and receptive speech and language function, language comprehension, speech production ability, spelling or writing with interpretation and report per hour.

Typical providerOften conducted by a speech-language therapist.

Benefit classificationNot considered psychological testing and is not typically covered under the behavioral health benefit.

ComponentsEvaluation includes assessment of expressive/receptive language, comprehension, speech production, and written language with interpretation and reporting.