CurrentPriority Health MedicarePolicy 91537

Neuropsychological and Psychological Testing

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This policy governs medical necessity and coverage criteria for neuropsychological and psychological testing, including applicable exclusions and billing codes. It applies to Priority Health products subject to the member’s specific benefit plan and, for Medicare members, CMS coverage determinations.

Policy Summary

PayerPriority Health Medicare

PolicyNeuropsychological and Psychological Testing

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument that testing is essential to developing a treatment plan or guiding treatment recommendations and identify the applicable clinical indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Testing categories addressed

11CPT/HCPCS codes listed

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CurrentPriority Health MedicarePolicy 91537

Neuropsychological and Psychological Testing

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Sign up for priority_health_medicare Policy 91537 alerts

Get alerted when Policy 91537 changes without checking for updates manually.

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Policy Summary

PayerPriority Health Medicare

PolicyNeuropsychological and Psychological Testing

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument that testing is essential to developing a treatment plan or guiding treatment recommendations and identify the applicable clinical indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Testing categories addressed

11CPT/HCPCS codes listed

Non-covered indication categories

F01-F99Covered diagnosis range

2Prior approval or plan considerations

0Changes to medical necessity criteria

Medical Necessity and Coverage Criteria

Neuropsychological Testing

Covered when testing is essential to developing a treatment plan and at least one qualifying indication applies.

Required medical necessity elements

Neuropsychological testing is required for diagnostic assessment essential to the development of a treatment plan.
Qualifying indications
- Persistent mental status change: A significant mental status change not due to a metabolic disorder has failed to respond to treatment.
- Pre-surgical or treatment-related cognitive evaluation: Evaluation is needed to determine whether the patient may safely proceed with a medical or surgical procedure that may affect brain function, such as deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery, or stem cell transplant.
- Differential neurocognitive assessment: Testing is needed to distinguish between the neurocognitive effects of a neurogenic syndrome, such as dementia, and major depressive disorder when adequate treatment for major depressive disorder has not resulted in improvement in neurocognitive function.
- Complex treatment participation assessment: Testing is needed to determine whether the patient can comprehend and participate effectively in a complex treatment regimen, such as transplant or bariatric surgery in a patient with diminished capacity.
- Behavioral, memory, or organic brain change with qualifying condition
  - The patient has a significant behavioral change, memory loss, or organic brain injury.
  - Qualifying neurologic or cerebral condition
    Traumatic brain injury.
    Stroke.
    Brain tumor.
    Cerebral anoxic or hypoxic episode.
    Central nervous system infection.

Psychological Testing

Covered when at least one of the following applies.

Qualifying indications

Diagnostic assessment: Testing is required for diagnostic assessment and differential diagnosis essential to guiding treatment recommendations.
Pre-surgical or premedical program: Psychological evaluation is a component of a pre-surgical or premedical program.
For coverage consideration, the related medical services must be prior-approved by Health Management. Examples include pre-surgical evaluations and evaluations for pain management programs.

Priority Health does not cover psychological or neuropsychological testing when performed primarily for educational purposes, vocational counseling or training, personnel or employment testing, routine inpatient admission or continued-stay batteries, legal or forensic purposes, or guardianship evaluation. Testing is also excluded when the patient cannot meaningfully participate, brain abnormalities are not suspected, repeated testing is not required for medical decision making, substance use would make results inaccurate or the patient is intoxicated, or prior brain dysfunction is not expected to affect medical management.

Testing associated with the listed ICD-10 diagnosis codes is not covered. These include codes related to borderline intellectual functioning, suicidal or homicidal ideation, speech disturbances, administrative or general examinations, education, employment, occupational exposure, social and psychosocial circumstances, abuse-related services, life-management difficulty, and personal history of mental and behavioral disorders. The listed codes are not exhaustive.

Testing is not medically necessary when it is primarily educational, vocational, employment-related, forensic, or administrative; when it consists of routine inpatient or continued-stay batteries; or when it is repetitive without a need for medical decision making. It is also not medically necessary when the patient cannot participate meaningfully, a brain abnormality is not suspected, ongoing substance use or intoxication would make results inaccurate, or testing is not expected to affect medical management.

Covered and Non-Covered Codes

Testing for these diagnosis codes is not coveredICD-10Not Covered

R41.83	Borderline intellectual functioning
R45.850-R45.851	Homicidal and suicidal ideations
R47.9	Unspecified speech disturbances
Z00.8	Encounter for other general examination
Z02.0-Z02.9	Encounter for administrative examination
Z04.6	Encounter for general psychiatric examination, requested by authority
Z04.8	Encounter for examination and observation for other specified reasons
Z53.1	Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure
Z55.0-Z55.9	Problems related to education and literacy
Z56.0-Z56.9	Problems related to employment and unemployment

1–10 of 19

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Behavioral health benefit diagnosis rangeICD-10Covered

F01-F99

Mental and behavioral disorders

CPT/HCPCS CodesCPTCovered

96116	Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report
96121	Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e.g., 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)
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 the patient, family member(s) or caregiver(s), when performed; 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) or caregiver(s), when performed; first hour
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 or 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)

1–10 of 11

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Authorization, Documentation, and Coverage Controls

Prior Authorization

Pre-Surgical or Premedical Approval

For psychological testing that is part of a pre-surgical and/or premedical program, the related medical services must be prior-approved by Health Management before coverage for the testing can be considered. Examples include pre-surgical evaluations and evaluations for pain management programs.

Prior Authorization

Conditional Prior Authorization

Prior authorization may or may not be required for particular services and procedures. When it is required, coverage remains subject to individual review and the applicable medical-necessity requirements.

Documentation Required

Support Medical Necessity

Document that neuropsychological or psychological testing is a diagnostic assessment essential to developing a treatment plan or guiding treatment recommendations. For neuropsychological testing, support the applicable clinical indication; for psychological testing, document the diagnostic or differential-diagnostic need and how results will guide treatment.

Clinical Background

Neuropsychological testing is a comprehensive, standardized, performance-based assessment of brain function and behavior. It may evaluate cognition, memory, language, executive function, motor and sensory skills, and visual-spatial abilities. Testing is used to identify or characterize deficits associated with conditions such as traumatic brain injury, stroke, dementia, epilepsy, multiple sclerosis, and developmental disorders, and to guide treatment, rehabilitation, or monitoring. Psychological testing additionally evaluates mental health, emotional functioning, personality, and general cognitive abilities to support diagnosis and treatment planning.

Testing Definitions

Neuropsychological testing

DefinitionA comprehensive, standardized assessment process used to evaluate the relationship between brain function and behavior.

Typical administratorClinical neuropsychologist

Psychological testing

DefinitionA broader category of assessment that evaluates an individual’s mental health, emotional functioning, personality traits, and general cognitive abilities.

Mental healthEvaluates mental health and emotional functioning.

Personality and cognitionAssesses personality traits and general cognitive abilities.

Typical administrator

Policy Summary

PayerPriority Health Medicare

PolicyNeuropsychological and Psychological Testing

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date09/01/2026

Next Review DateN/A

Key ActionDocument that testing is essential to developing a treatment plan or guiding treatment recommendations and identify the applicable clinical indication.

SourceLink

On This Page

Neoplasm or vascular injury of the central nervous system.

Neurodegenerative disorder.

Demyelinating disease.

Extrapyramidal disease.

Exposure to intrathecal agents or cranial radiation known to be associated with cerebral dysfunction.

Significant mental-status, behavioral, memory, neurocognitive, or organic-brain-function concerns may support neuropsychological testing when the policy criteria are met.
Testing may support evaluation of cognitive safety for a procedure, ability to participate in complex treatment, or distinction between neurocognitive and psychiatric conditions.

Prior Authorization

Submit Prior Authorization

When prior authorization is required, submit a request demonstrating that the service is medically necessary. Refer to the Priority Health Provider Manual for neuropsychological and psychological testing requirements.

Denial Risk

Excluded Testing Indications

Testing is not covered under either the medical or behavioral health benefit when performed primarily for excluded indications or when the policy’s clinical exclusion criteria apply.

Educational purposes or vocational counseling or training
Personnel or employment testing
Routine psychological-test batteries at inpatient admission or continued stay
Legal or forensic purposes or guardianship evaluation
When the patient cannot participate meaningfully because of neurological or cognitive limitations
When brain abnormalities are not suspected
Repeated testing not required for medical decision making
Testing during ongoing substance use that would make results inaccurate or while the patient is intoxicated
Previously diagnosed brain dysfunction when testing is not expected to affect medical management

Denial Risk

Non-Covered Diagnosis Codes

Testing associated with the diagnosis codes below is not covered. This list is not exhaustive; review the complete policy and applicable coding guidance before billing.

R41.83 — Borderline intellectual functioning
R45.850–R45.851 — Homicidal and suicidal ideations
R47.9 — Unspecified speech disturbances
Z00.8 — Encounter for other general examination
Z02.0–Z02.9 — Encounter for administrative examination
Z04.6 — Encounter for general psychiatric examination, requested by authority
Z04.8 — Encounter for examination and observation for other specified reasons
Z53.1 — Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure
Z55.0–Z55.9 — Problems related to education and literacy
Z56.0–Z56.9 — Problems related to employment and unemployment
Z57.0–Z57.9 — Occupational exposure to risk factors
Z60.0–Z60.9 — Problems related to social environment
Z62.0–Z62.9 — Problems related to upbringing
Z63.0–Z63.9 — Other problems related to primary support group, including family circumstances
Z64.0–Z64.4 — Problems related to certain psychosocial circumstances
Z65.0–Z65.9 — Problems related to other psychosocial circumstances
Z69.010–Z69.82 — Encounter for mental health services for victim and perpetrator of abuse
Z73.0–Z73.6 — Problems related to life-management difficulty
Z86.59 — Personal history of other mental and behavioral disorders

Note

Plan-Specific Coverage Controls

Apply the member’s specific benefits and governing coverage documents when determining coverage. For Medicare members, CMS coverage determinations govern; if CMS has not adopted a determination, this policy applies.

Group-specific policy supersedes this policy when applicable.
Plan documents govern when they conflict with this policy, including for PPO, ASO, and individual products.
State-mandated benefits may apply; consult the applicable plan documents.
For Medicaid/Healthy Michigan Plan members, the Michigan Medicaid Provider Manual, contract, and applicable fee schedule may govern when there is a discrepancy or lack of guidance.

Clinical psychologist